Basic Information
Provider Information | |||||||||
NPI: | 1306919857 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | MELODEE | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALKER | ||||||||
OtherFirstName: | MELODEE | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4301 W MARKHAM ST # 783 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722057101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016868000 | ||||||||
FaxNumber: | 5015265148 | ||||||||
Practice Location | |||||||||
Address1: | 629 JACK STEPHENS DR | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722055525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5015265798 | ||||||||
FaxNumber: | 5016866234 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 09/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0600X | A01739ANP | AR | N |   | Nursing Service Providers | Registered Nurse | Gerontology | 363LG0600X | A001739 | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 163WG0600X | R70398 | AR | N |   | Nursing Service Providers | Registered Nurse | Gerontology |
No ID Information.