Provider Demographics
NPI:1508044363
Name:AVERY, MELISSA VOSCHE' RUTLAND (MD MMM CPEFAAFPFAAPL)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:VOSCHE' RUTLAND
Last Name:AVERY
Suffix:
Gender:F
Credentials:MD MMM CPEFAAFPFAAPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 CHANDAMERE WAY
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-6008
Mailing Address - Country:US
Mailing Address - Phone:615-818-1967
Mailing Address - Fax:
Practice Address - Street 1:2301 GREENUP AVE STE 8A
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7869
Practice Address - Country:US
Practice Address - Phone:859-303-9436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35143174400000X, 207Q00000X
SC19882207Q00000X
TN32240207Q00000X
NV12682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000705140OtherANTHEM-NICC
KY7100123760Medicaid
KY7100123760Medicaid
KY000000705140OtherANTHEM-NICC