Provider Demographics
NPI:1477091122
Name:SIDWELL, MELANI (NP)
Entity Type:Individual
Prefix:
First Name:MELANI
Middle Name:
Last Name:SIDWELL
Suffix:
Gender:F
Credentials:NP
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 3572
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38303-3572
Mailing Address - Country:US
Mailing Address - Phone:731-668-1853
Mailing Address - Fax:731-664-7731
Practice Address - Street 1:131 TUCKER STREET
Practice Address - Street 2:STE 2
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-668-1853
Practice Address - Fax:731-664-7731
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN121210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN121210OtherRN