Provider Demographics
NPI:1225529456
Name:MELTON, PENNY
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:MELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 E BAY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1399
Mailing Address - Country:US
Mailing Address - Phone:810-208-7080
Mailing Address - Fax:
Practice Address - Street 1:3043 E BAY DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1399
Practice Address - Country:US
Practice Address - Phone:810-208-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276828163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse