Provider Demographics
NPI:1700219102
Name:MELVIN, SAMANTHA JO (APRN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:MELVIN
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:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:617 23RD ST STE 215
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2870
Practice Address - Country:US
Practice Address - Phone:606-408-1260
Practice Address - Fax:606-408-6327
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008231363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091405Medicaid
KY7100259280Medicaid
KYK083730Medicare PIN