Provider Demographics
NPI:1518493683
Name:KING, MELODY SUE (APRN)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:SUE
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:SUE
Other - Last Name:BOURBEAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:822 YOUNGS LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-2629
Mailing Address - Country:US
Mailing Address - Phone:513-516-1453
Mailing Address - Fax:
Practice Address - Street 1:822 YOUNGS LANE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245
Practice Address - Country:US
Practice Address - Phone:513-516-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH026761363LA2200X
OH020761313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility