Provider Demographics
NPI:1033211958
Name:MOORMAN, MELLISA (NP)
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:
Last Name:MOORMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 BARNHILL DR
Mailing Address - Street 2:EH 203
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5112
Mailing Address - Country:US
Mailing Address - Phone:317-274-3086
Mailing Address - Fax:317-481-1337
Practice Address - Street 1:545 BARNHILL DR
Practice Address - Street 2:EH 203
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5112
Practice Address - Country:US
Practice Address - Phone:317-274-3086
Practice Address - Fax:317-481-1337
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002053A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner