1922193812 NPI number — MELISSA NICKELS STACY P.A.C.

Table of content: MELISSA NICKELS STACY P.A.C. (NPI 1922193812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922193812 NPI number — MELISSA NICKELS STACY P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACY
Provider First Name:
MELISSA
Provider Middle Name:
NICKELS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922193812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 BEN BOLT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAZEWELL
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24651-9700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-988-8850
Provider Business Mailing Address Fax Number:
276-988-8786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 MEDICAL PARK DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUEFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24605-1531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-322-5400
Provider Business Practice Location Address Fax Number:
276-322-5777
Provider Enumeration Date:
10/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  0110840809 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)