Provider Demographics
NPI:1356314157
Name:STANLEY, MELANIE VICKERY (PAC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:VICKERY
Last Name:STANLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31010
Mailing Address - Country:US
Mailing Address - Phone:229-271-4656
Mailing Address - Fax:229-271-4654
Practice Address - Street 1:4110 BEDGOOD AVE
Practice Address - Street 2:
Practice Address - City:ARABI
Practice Address - State:GA
Practice Address - Zip Code:31712
Practice Address - Country:US
Practice Address - Phone:229-273-0116
Practice Address - Fax:229-273-4853
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002127363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S16438Medicare UPIN
97BBCHZMedicare ID - Type Unspecified