Provider Demographics
NPI:1902362593
Name:SOUTHWELL, MELISSA M (CNM)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 PENTAGON BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1705
Mailing Address - Country:US
Mailing Address - Phone:651-442-5343
Mailing Address - Fax:
Practice Address - Street 1:3535 PENTAGON BLVD STE 220
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-429-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CNM05077176B00000X
OHAPRN.CNM.0019574367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife