Provider Demographics
NPI:1891412490
Name:MELLON, LORA
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 LEO LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-8466
Mailing Address - Country:US
Mailing Address - Phone:681-588-7715
Mailing Address - Fax:
Practice Address - Street 1:153 LEO LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:WV
Practice Address - Zip Code:26181-8466
Practice Address - Country:US
Practice Address - Phone:681-588-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36191164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
630435OtherWORKERS COMP