Provider Demographics
NPI:1790814788
Name:OUTLAW, MELENA (BA)
Entity Type:Individual
Prefix:MRS
First Name:MELENA
Middle Name:
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:BA
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 1403
Mailing Address - Street 2:
Mailing Address - City:JENKINS
Mailing Address - State:KY
Mailing Address - Zip Code:41537-1403
Mailing Address - Country:US
Mailing Address - Phone:606-832-1473
Mailing Address - Fax:606-832-0397
Practice Address - Street 1:457 BENTLEY LOOP
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537-9004
Practice Address - Country:US
Practice Address - Phone:606-832-1473
Practice Address - Fax:606-832-0397
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist