Basic Information
| Provider Information | |||||||||
| NPI: | 1609425107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TODD | ||||||||
| FirstName: | MELISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 PEMBERTON CV | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383055514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7313941145 | ||||||||
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| Practice Location | |||||||||
| Address1: | 867 MCGUIRE AVE | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420014036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704426168 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2019 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3013427 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.