Provider Demographics
NPI:1811578909
Name:HENDERSON, MELODY DAWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:DAWN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:FNP-C
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 204
Mailing Address - Street 2:
Mailing Address - City:HAMBLETON
Mailing Address - State:WV
Mailing Address - Zip Code:26269-0204
Mailing Address - Country:US
Mailing Address - Phone:304-704-6820
Mailing Address - Fax:
Practice Address - Street 1:169 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3706
Practice Address - Country:US
Practice Address - Phone:304-591-9154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF0202935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily