MEDICARE: MELISSA LEE MATHIAS FNP-BC

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	71048	WV

General Provider Information

NPI Number	:	1801146071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA LEE MATHIAS FNP-BC

Provider Business Mailing Address
First Line	:	3647 US HIGHWAY 220 N
Second Line	:
City	:	MOOREFIELD
State	:	WV
Zip	:	26836-8643
Country	:	US
Telephone Number	:	304-538-3131
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 MULLIGAN DRIVE
Second Line	:
City	:	PETERSBURG
State	:	WV
Zip	:	26847-1511
Country	:	US
Telephone Number	:	304-257-2451
Fax Number	:

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

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	05/04/2015

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