Provider Demographics
NPI:1659077238
Name:BLACK, MELISSA MARIE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1375
Mailing Address - Country:US
Mailing Address - Phone:916-204-7056
Mailing Address - Fax:
Practice Address - Street 1:37 S 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1906
Practice Address - Country:US
Practice Address - Phone:208-356-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59333163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse