Basic Information
| Provider Information | |||||||||
| NPI: | 1063640985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1325 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407021325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065268131 | ||||||||
| FaxNumber: | 6065288661 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 W CUMBERLAND GAP PKWY | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407014819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065231565 | ||||||||
| FaxNumber: | 6065264448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1567 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100285080 | 05 | KY | MEDICAID | PA1567 | 01 | KY | MEDICAL LICENSE | OTHER | P01439783 | 01 | KY | RR MEDICARE | OTHER |