Provider Demographics
NPI:1073063293
Name:MELLOTT, DAPHNE (HEAVENLY HEARTS LLC)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:HEAVENLY HEARTS LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 25TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647-5139
Mailing Address - Country:US
Mailing Address - Phone:330-209-8999
Mailing Address - Fax:
Practice Address - Street 1:561 25TH ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5139
Practice Address - Country:US
Practice Address - Phone:330-209-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH47-17226552OtherEIN