Provider Demographics
NPI:1881672137
Name:WALLACE, MELYNDA KAYE (CRNA, APRN)
Entity Type:Individual
Prefix:MS
First Name:MELYNDA
Middle Name:KAYE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 ROUTE 10 N UNIT 2
Mailing Address - Street 2:
Mailing Address - City:GRANTHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03753-3621
Mailing Address - Country:US
Mailing Address - Phone:603-309-3902
Mailing Address - Fax:603-843-8176
Practice Address - Street 1:151 ROUTE 10 N UNIT 2
Practice Address - Street 2:
Practice Address - City:GRANTHAM
Practice Address - State:NH
Practice Address - Zip Code:03753-3621
Practice Address - Country:US
Practice Address - Phone:603-309-3902
Practice Address - Fax:603-843-8176
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH040072-23-11363L00000X
NH040072-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008569Medicaid
NH1008569Medicaid