Provider Demographics
NPI:1811415540
Name:KOONCE, MELISSA CAROL (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAROL
Last Name:KOONCE
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 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:870-541-7211
Mailing Address - Fax:
Practice Address - Street 1:1609 W 40TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6367
Practice Address - Country:US
Practice Address - Phone:870-534-1188
Practice Address - Fax:870-541-4297
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARA005340363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology