Provider Demographics
NPI:1922193812
Name:STACY, MELISSA NICKELS (PAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICKELS
Last Name:STACY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 BEN BOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-9700
Mailing Address - Country:US
Mailing Address - Phone:276-988-8850
Mailing Address - Fax:276-988-8786
Practice Address - Street 1:231 MEDICAL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-1531
Practice Address - Country:US
Practice Address - Phone:276-322-5400
Practice Address - Fax:276-322-5777
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840809363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP65167Medicare UPIN