Basic Information
Provider Information | |||||||||
NPI: | 1265590558 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOSTER | ||||||||
FirstName: | MELODY | ||||||||
MiddleName: | O. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | REGISTERED NURSE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 895 STATE FARM ROAD | ||||||||
Address2: | SUITE 508 | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286073515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282649007 | ||||||||
FaxNumber: | 8282625687 | ||||||||
Practice Location | |||||||||
Address1: | 1430 WILLOW LANE | ||||||||
Address2: | WEST PARK C61-2 | ||||||||
City: | NORTH WILKESBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 286593551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3366675151 | ||||||||
FaxNumber: | 8282625687 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 175687 | NC | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 01 | NC | TRICARE PROVIDER ID # | OTHER |