Provider Demographics
NPI:1841684040
Name:DAVIS, MELISSA MAY (STNA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MAY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 NEWGARDEN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3040
Mailing Address - Country:US
Mailing Address - Phone:330-277-1272
Mailing Address - Fax:
Practice Address - Street 1:311 NEWGARDEN AVE APT A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3040
Practice Address - Country:US
Practice Address - Phone:330-277-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3087092Medicaid