Provider Demographics
NPI:1639206378
Name:HAIST, MELODY (NP)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:
Last Name:HAIST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1256
Mailing Address - Country:US
Mailing Address - Phone:765-914-5847
Mailing Address - Fax:765-373-8579
Practice Address - Street 1:1501 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1914
Practice Address - Country:US
Practice Address - Phone:765-962-1337
Practice Address - Fax:765-935-7509
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000841A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71000841AOtherSTATE LICENSE