Provider Demographics
NPI:1275008724
Name:JIMENEZ, MELISSA LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LEE
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4708 W STATE ROAD 114
Mailing Address - Street 2:
Mailing Address - City:NORTH MANCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46962-8680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:NORTH MANCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46962-1857
Practice Address - Country:US
Practice Address - Phone:260-982-1994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008457A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner