Provider Demographics
NPI:1033879168
Name:REVARD, MELISSA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:REVARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6083 S 300 E
Mailing Address - Street 2:
Mailing Address - City:MARKLEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46056-9755
Mailing Address - Country:US
Mailing Address - Phone:574-229-0552
Mailing Address - Fax:
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-338-6815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28201775A163WP0200X
IN71012244A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics