Provider Demographics
NPI:1376098574
Name:PATILLO, MELISSA A (AGPCNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:PATILLO
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:HOTALING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-7040
Mailing Address - Fax:757-446-7049
Practice Address - Street 1:825 FAIRFAX AVE STE 201
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-7040
Practice Address - Fax:757-446-7049
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001208112163W00000X
VA0015001015364SG0600X
VA0024174616363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1376098574Medicaid
VA1376098574Medicaid
VA1376098574OtherCORVEL
VA1376098574OtherUSA MANAGED CARE
VA1376098574OtherVIRGINIA HEALTH NETWORK
VA1376098574OtherTRICARE/CHAMPUS
VA1376098574OtherHUMANA
VAQMBMedicaid
VAVVM642AMedicare PIN