Provider Demographics
NPI:1679845192
Name:DOUGLAS, MELINDA A (CRNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:A
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-5266
Mailing Address - Fax:814-373-5269
Practice Address - Street 1:640 ALDEN ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2348
Practice Address - Country:US
Practice Address - Phone:814-373-5266
Practice Address - Fax:814-373-5269
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011406363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP011406OtherPA STATE BOARD OF NURSING