Provider Demographics
NPI:1609417971
Name:SMITH, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
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 1:11404 W DODGE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2511
Mailing Address - Country:US
Mailing Address - Phone:402-898-1113
Mailing Address - Fax:402-819-5588
Practice Address - Street 1:11404 W DODGE RD STE 300
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2511
Practice Address - Country:US
Practice Address - Phone:402-898-1113
Practice Address - Fax:402-819-5588
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE64078163WP0200X, 163WS0200X
NE114556363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WS0200XNursing Service ProvidersRegistered NurseSchool