Provider Demographics
NPI:1659109577
Name:MELTON, KENZIE ROSE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KENZIE
Middle Name:ROSE
Last Name:MELTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 COUNTY ROAD 082
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-7036
Mailing Address - Country:US
Mailing Address - Phone:409-594-7829
Mailing Address - Fax:
Practice Address - Street 1:109 TIMBERLAND HWY
Practice Address - Street 2:
Practice Address - City:PINELAND
Practice Address - State:TX
Practice Address - Zip Code:75968-4012
Practice Address - Country:US
Practice Address - Phone:409-217-3900
Practice Address - Fax:409-584-2210
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1169184363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily