Provider Demographics
NPI:1497801559
Name:MCDANIEL, MELINDA LEE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:LEE
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:MELINDA
Other - Middle Name:LEE
Other - Last Name:COGDILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:378 MARKETPLACE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2361
Practice Address - Country:US
Practice Address - Phone:423-282-0751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN15554363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522665Medicaid
TN103I501720Medicare PIN