MEDICARE: MELISSA ANN QUEEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker

General Provider Information

NPI Number	:	1558967422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA ANN QUEEN

Provider Business Mailing Address
First Line	:	159 MILL ST E
Second Line	:
City	:	RUSHSYLVANIA
State	:	OH
Zip	:	43347-9763
Country	:	US
Telephone Number	:	937-407-1774
Fax Number	:

Provider Business Practice Location Address
First Line	:	159 MILL ST E
Second Line	:
City	:	RUSHSYLVANIA
State	:	OH
Zip	:	43347-9763
Country	:	US
Telephone Number	:	937-407-1774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	12/07/2020

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Directions to “ MELISSA ANN QUEEN ” Practice Location

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