1346426871 NPI number — MS. GINA DIDAWICK MELLOTT RN

Table of content: MS. GINA DIDAWICK MELLOTT RN (NPI 1346426871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346426871 NPI number — MS. GINA DIDAWICK MELLOTT RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLOTT
Provider First Name:
GINA
Provider Middle Name:
DIDAWICK
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIDAWICK
Provider Other First Name:
GINA
Provider Other Middle Name:
CAROLINE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346426871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
398 THEO HOVERMALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY SPGS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-258-1058
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
247 HARRISON AVENUE
Provider Second Line Business Practice Location Address:
MORGAN COUNTY BOARD OF EDUCATION
Provider Business Practice Location Address City Name:
BERKELEY SPGS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-258-2430
Provider Business Practice Location Address Fax Number:
304-258-4600
Provider Enumeration Date:
01/15/2008

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: 163W00000X , with the licence number:  47342 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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