Provider Demographics
NPI:1063640985
Name:HALE, MELISSA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MARIE
Last Name:HALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:446 W CUMBERLAND GAP PKWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4819
Practice Address - Country:US
Practice Address - Phone:606-523-1565
Practice Address - Fax:606-526-4448
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100285080Medicaid
KYPA1567OtherMEDICAL LICENSE
KYP01439783OtherRR MEDICARE
KYPA1567OtherMEDICAL LICENSE