Provider Demographics
NPI:1922250364
Name:SAMPLE, MELISSA (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2074 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-3372
Mailing Address - Country:US
Mailing Address - Phone:541-880-2011
Mailing Address - Fax:
Practice Address - Street 1:103 WASO
Practice Address - Street 2:
Practice Address - City:CHILOQUIN
Practice Address - State:OR
Practice Address - Zip Code:97624
Practice Address - Country:US
Practice Address - Phone:541-880-2011
Practice Address - Fax:541-783-3273
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099000635RN163W00000X
OR200850150NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse