Provider Demographics
NPI:1932815339
Name:KANNU-MELSON, RUNGNAPA (NP)
Entity Type:Individual
Prefix:
First Name:RUNGNAPA
Middle Name:
Last Name:KANNU-MELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RUNGNAPA
Other - Middle Name:
Other - Last Name:KANNU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:
Practice Address - Street 1:340 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2421
Practice Address - Country:US
Practice Address - Phone:931-783-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33270363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33270OtherAPN LICENSE
TNQ082008Medicaid