1043249410 NPI number — MELISSA STILL PT

Table of content: MELISSA STILL PT (NPI 1043249410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043249410 NPI number — MELISSA STILL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STILL
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OWENS
Provider Other First Name:
MELISSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043249410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3291 S THOMPSON ST
Provider Second Line Business Mailing Address:
SUITE C103
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72764-7043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-750-3535
Provider Business Mailing Address Fax Number:
479-750-3539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3291 S THOMPSON ST
Provider Second Line Business Practice Location Address:
SUITE C103
Provider Business Practice Location Address City Name:
SPRINGDALE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72764-7043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-750-3535
Provider Business Practice Location Address Fax Number:
479-750-3539
Provider Enumeration Date:
06/30/2006

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: 225100000X , with the licence number:  2864 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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