Provider Demographics
NPI:1396269155
Name:LOPER, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LOPER
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 1:364 SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-4235
Mailing Address - Country:US
Mailing Address - Phone:239-789-7197
Mailing Address - Fax:
Practice Address - Street 1:364 SOUTHGATE DR
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-4235
Practice Address - Country:US
Practice Address - Phone:239-789-7197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF07171030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily