Provider Demographics
NPI:1568077055
Name:GANDEE, MELISSA LYNN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:GANDEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22394 LAKE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-3467
Mailing Address - Country:US
Mailing Address - Phone:330-596-0710
Mailing Address - Fax:
Practice Address - Street 1:22394 LAKE PARK BLVD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3467
Practice Address - Country:US
Practice Address - Phone:330-596-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5005964385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5005964Medicaid
OH5005964OtherDODD