Basic Information
| Provider Information | |||||||||
| NPI: | 1700219102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411051595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 23RD ST STE 215 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064081260 | ||||||||
| FaxNumber: | 6064086327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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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 | 3008231 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0091405 | 05 | OH | MEDICAID | 7100259280 | 05 | KY | MEDICAID |