Provider Demographics
NPI:1235787250
Name:MILLARD, MELISSA ANN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MILLARD
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 1:1500 O AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NE
Mailing Address - Zip Code:68743-3072
Mailing Address - Country:US
Mailing Address - Phone:712-898-8391
Mailing Address - Fax:
Practice Address - Street 1:6120 MORNINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-3943
Practice Address - Country:US
Practice Address - Phone:712-276-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01135225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty