Provider Demographics
NPI:1518036367
Name:POTTS-TRIPPE, MELINDA SUE (LMBT #101)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:SUE
Last Name:POTTS-TRIPPE
Suffix:
Gender:F
Credentials:LMBT #101
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 KAREN CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-1540
Mailing Address - Country:US
Mailing Address - Phone:336-767-7272
Mailing Address - Fax:336-767-7211
Practice Address - Street 1:230 KAREN CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-1540
Practice Address - Country:US
Practice Address - Phone:336-767-7272
Practice Address - Fax:336-767-7211
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLMBT #101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLMBT #101OtherLICENSE