Provider Demographics
NPI:1740061951
Name:DOUGLASS, MELANIE HERNANDEZ
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:HERNANDEZ
Last Name:DOUGLASS
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 1:2801 WILSHIRE HILL DR UNIT 105
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5302
Mailing Address - Country:US
Mailing Address - Phone:919-282-2746
Mailing Address - Fax:
Practice Address - Street 1:7201 US HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-9268
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5019002363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily