Provider Demographics
NPI:1467048876
Name:PROCTOR, MERIELLE KAYTE
Entity Type:Individual
Prefix:
First Name:MERIELLE
Middle Name:KAYTE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 DIMPLE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3909
Mailing Address - Country:US
Mailing Address - Phone:931-446-0485
Mailing Address - Fax:
Practice Address - Street 1:1815 DIMPLE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3909
Practice Address - Country:US
Practice Address - Phone:931-446-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant