Provider Demographics
NPI:1831647262
Name:MOBLEY, MELANIE (AGPCNP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MOBLEY
Suffix:
Gender:F
Credentials:AGPCNP
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 5
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-0005
Mailing Address - Country:US
Mailing Address - Phone:573-996-4017
Mailing Address - Fax:
Practice Address - Street 1:210 NE TUDOR RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5696
Practice Address - Country:US
Practice Address - Phone:888-256-3814
Practice Address - Fax:888-256-9054
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MO2016029751363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA6143Medicare PIN