Provider Demographics
NPI:1811906423
Name:STATHAM, MELISSA CATHERINE (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CATHERINE
Last Name:STATHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-1089
Mailing Address - Country:US
Mailing Address - Phone:907-442-2544
Mailing Address - Fax:
Practice Address - Street 1:436 5TH & TED STEVENS WAY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-0043
Practice Address - Country:US
Practice Address - Phone:907-442-3321
Practice Address - Fax:907-442-7250
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1295993376Medicaid
AZ1871523191Medicaid
AZ1629236716Medicaid
AZ1780614008Medicaid
AZ1629236716Medicaid
AK021310Medicare Oscar/Certification