Provider Demographics
NPI:1841391851
Name:MELLOH, KATHLEEN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:MELLOH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:2 W 42ND ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-0617
Mailing Address - Country:US
Mailing Address - Phone:308-635-1414
Mailing Address - Fax:308-635-1913
Practice Address - Street 1:2 W 42ND ST
Practice Address - Street 2:SUITE 120
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-0617
Practice Address - Country:US
Practice Address - Phone:308-635-1414
Practice Address - Fax:308-635-1913
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-05-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE1605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP88076Medicare UPIN