Healthcare Provider Details

I. General information

NPI: 1578876538
Provider Name (Legal Business Name): MRS. MELISSA LEASE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 HEDGESVILLE RD
HEDGESVILLE WV
25427-5483
US

IV. Provider business mailing address

11955 BACK CREEK VALLEY RD
HEDGESVILLE WV
25427-3156
US

V. Phone/Fax

Practice location:
  • Phone: 304-754-3171
  • Fax:
Mailing address:
  • Phone: 304-754-6048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number72755
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: