=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912350513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELODEE B THACKER APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2016
-----------------------------------------------------
Last Update Date | 11/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5900 ROUTE US 60 W SUITE B
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-393-5586
-----------------------------------------------------
Fax | 606-928-5547
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5900 ROUTE US 60 W SUITE B
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-393-5586
-----------------------------------------------------
Fax | 606-928-5547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | APRN.CNP.020075
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 1145293
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------