Provider Demographics
NPI:1912350513
Name:THACKER, MELODEE B (APRN)
Entity Type:Individual
Prefix:
First Name:MELODEE
Middle Name:B
Last Name:THACKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 ROUTE US 60 W SUITE B
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102
Mailing Address - Country:US
Mailing Address - Phone:606-393-5586
Mailing Address - Fax:606-928-5547
Practice Address - Street 1:5900 ROUTE US 60 W SUITE B
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102
Practice Address - Country:US
Practice Address - Phone:606-393-5586
Practice Address - Fax:606-928-5547
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020075364SP0809X
KY11452932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult