Provider Demographics
NPI:1669021796
Name:PRICKETT, MELISSA (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PRICKETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 N 173RD CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-3148
Mailing Address - Country:US
Mailing Address - Phone:402-304-9069
Mailing Address - Fax:
Practice Address - Street 1:14000 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010
Practice Address - Country:US
Practice Address - Phone:531-355-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE112952OtherSTATE BOARD OF NURSING