Provider Demographics
NPI:1326339250
Name:MEHAFFEY, MELISSA A
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MEHAFFEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:BUONGIORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 KELLUM ST
Mailing Address - Street 2:APT 406
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4179
Mailing Address - Country:US
Mailing Address - Phone:907-987-4095
Mailing Address - Fax:
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-455-5304
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
AKMH0157Medicaid