Provider Demographics
NPI:1376046649
Name:BOLT, MELISSA CLARK (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CLARK
Last Name:BOLT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4138 MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-4225
Mailing Address - Country:US
Mailing Address - Phone:276-340-1142
Mailing Address - Fax:276-956-5050
Practice Address - Street 1:4138 MITCHELL RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-4225
Practice Address - Country:US
Practice Address - Phone:276-340-1142
Practice Address - Fax:276-956-5050
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63345963343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)