Provider Demographics
NPI:1326249988
Name:PURK, MELISSA ELOISE (STNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ELOISE
Last Name:PURK
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-1472
Mailing Address - Country:US
Mailing Address - Phone:937-652-2768
Mailing Address - Fax:
Practice Address - Street 1:149 MADISON AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-2289
Practice Address - Country:US
Practice Address - Phone:937-652-2768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400700261207376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide