Provider Demographics
NPI:1265103261
Name:SLACK, MELISSA DAWN (APRN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:SLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12134 OLD DAYTON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-8361
Mailing Address - Country:US
Mailing Address - Phone:937-416-8874
Mailing Address - Fax:
Practice Address - Street 1:12134 OLD DAYTON RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-8361
Practice Address - Country:US
Practice Address - Phone:937-416-8874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP.0029805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine