Provider Demographics
NPI:1821074360
Name:KNUCKLES, MELISSA LOUELLEN FORESTER (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LOUELLEN FORESTER
Last Name:KNUCKLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MASTER ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-3511
Mailing Address - Country:US
Mailing Address - Phone:606-528-2881
Mailing Address - Fax:696-528-0293
Practice Address - Street 1:1101 EAST MASTER STREET
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-3511
Practice Address - Country:US
Practice Address - Phone:606-528-2881
Practice Address - Fax:696-528-0293
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22360207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64223605Medicaid
4114Medicare ID - Type Unspecified
U98504Medicare UPIN