1669097119 NPI number — MELANIE NICOLE BECKHAM RN, PMHNP

Table of content: MELANIE NICOLE BECKHAM RN, PMHNP (NPI 1669097119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669097119 NPI number — MELANIE NICOLE BECKHAM RN, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BECKHAM
Provider First Name:
MELANIE
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, PMHNP
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:
1669097119
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18614 JACKSON STREET
Provider Second Line Business Mailing Address:
PO BOX 125
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-745-2121
Provider Business Mailing Address Fax Number:
417-745-0056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 SOUTH SPRINGFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-326-7272
Provider Business Practice Location Address Fax Number:
417-326-2193
Provider Enumeration Date:
06/10/2020

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: 363LP0808X , with the licence number:  2020012746 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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