Provider Demographics
NPI:1407245483
Name:BOONE, MELISSA MOORE MEYER (AA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MOORE MEYER
Last Name:BOONE
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MOORE
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:2308 WESVILL CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-2949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2308 WESVILL CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2949
Practice Address - Country:US
Practice Address - Phone:919-781-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007369367H00000X
FLAA318367H00000X
NC2000-00003367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016135200Medicaid
FL016135200Medicaid