Provider Demographics
NPI:1619199387
Name:SELL, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:SELL
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 1:2601 HOLLER AVE.
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414
Mailing Address - Country:US
Mailing Address - Phone:307-272-7755
Mailing Address - Fax:307-527-7270
Practice Address - Street 1:2601 HOLLER AVE.
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414
Practice Address - Country:US
Practice Address - Phone:307-272-7755
Practice Address - Fax:307-527-7270
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0600012800Medicaid
WI0600397906Medicaid
WY124649OtherTRADING PARTNER NUMBER