Provider Demographics
NPI:1073145751
Name:PERRY, MELLISA (RN)
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PARKER LN
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-8071
Mailing Address - Country:US
Mailing Address - Phone:606-776-2446
Mailing Address - Fax:
Practice Address - Street 1:1220 GREENUP AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7525
Practice Address - Country:US
Practice Address - Phone:606-393-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1165520163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)