Provider Demographics
NPI:1770477663
Name:THACKER, MELISA REBECCA (FNP-BC)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:REBECCA
Last Name:THACKER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POPLAR RD STE 240
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8300
Mailing Address - Country:US
Mailing Address - Phone:770-400-7830
Mailing Address - Fax:
Practice Address - Street 1:775 POPLAR RD STE 240
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8300
Practice Address - Country:US
Practice Address - Phone:770-400-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38908363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner