Basic Information
| Provider Information | |||||||||
| NPI: | 1114220472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3889 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945580 | ||||||||
| FaxNumber: | 4232328561 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945580 | ||||||||
| FaxNumber: | 4232328561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 14376 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1522234 | 05 | TN | MEDICAID | 4289807 | 01 | TN | BCBS | OTHER |