1497000657 NPI number — MRS. MELISSA MARTIN BREAUX FNP-C

Table of content: MRS. MELISSA MARTIN BREAUX FNP-C (NPI 1497000657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497000657 NPI number — MRS. MELISSA MARTIN BREAUX FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREAUX
Provider First Name:
MELISSA
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
MELISSA
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497000657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1233 WAYNE GILMORE CIRCLE
Provider Second Line Business Mailing Address:
STE 250-B
Provider Business Mailing Address City Name:
OPELOUSAS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70570-6405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-407-1955
Provider Business Mailing Address Fax Number:
337-407-1956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1233 WAYNE GILMORE CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 250-B
Provider Business Practice Location Address City Name:
OPELOUSAS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70570-6405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-407-1955
Provider Business Practice Location Address Fax Number:
337-407-1956
Provider Enumeration Date:
07/13/2012

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: 363L00000X , with the licence number:  RN063199/AP06875 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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