Provider Demographics
NPI:1235161902
Name:MASSIE, MELBA MECHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MELBA
Middle Name:MECHELLE
Last Name:MASSIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELBA
Other - Middle Name:MECHELLE
Other - Last Name:WOOLLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1000 ASHLAND DR STE 103
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7092
Practice Address - Country:US
Practice Address - Phone:606-324-0098
Practice Address - Fax:606-324-0315
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000609841OtherANTHEM BCBS
KY95006086Medicaid
KY000000608782OtherANTHEM BCBS
KY00953004Medicare PIN
KY00953010Medicare PIN
KY000000609841OtherANTHEM BCBS
KYP00392488Medicare PIN
KY000000608782OtherANTHEM BCBS