Provider Demographics
NPI:1790986909
Name:CLEMONS, MELISSA H
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:H
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1275
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:
Practice Address - Street 1:4438 BEAVER DAM RD
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-9086
Practice Address - Country:US
Practice Address - Phone:270-879-6059
Practice Address - Fax:270-879-8117
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid
KY01948OtherFIRST STEPS PROVIDER ID