=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316683253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANN FOUTZ FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2022
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 SLAPSHOT DR
-----------------------------------------------------
City | FORISTELL
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63348-2699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-578-4549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 SLAPSHOT DR
-----------------------------------------------------
City | FORISTELL
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63348-2699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-578-4549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F04220327
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------