MEDICARE: MRS. KENZIE ROSE MELTON FNP-C

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	363LF0000X	Family Nurse Practitioner	1169184	TX

General Provider Information

NPI Number	:	1659109577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KENZIE ROSE MELTON FNP-C

Provider Business Mailing Address
First Line	:	404 COUNTY ROAD 082
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-7036
Country	:	US
Telephone Number	:	409-594-7829
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 TIMBERLAND HWY
Second Line	:
City	:	PINELAND
State	:	TX
Zip	:	75968-4012
Country	:	US
Telephone Number	:	409-217-3900
Fax Number	:	409-584-2210

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

Provider Enumeration Date	:	07/23/2024
Last Update Date	:	07/23/2024

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Directions to “ MRS. KENZIE ROSE MELTON FNP-C” Practice Location

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