Provider Demographics
NPI:1720062151
Name:BEACH, MELISSA (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BEACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BLOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST # 71
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8253
Mailing Address - Fax:269-341-7847
Practice Address - Street 1:601 JOHN ST # 71
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8253
Practice Address - Fax:269-341-7847
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704208587363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4780901-10Medicaid
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MIG56008 124Medicare ID - Type Unspecified
MI230015Medicare Oscar/Certification
MIP84324Medicare UPIN