Basic Information
| Provider Information | |||||||||
| NPI: | 1144579848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETCHISON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | N.P, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472016264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127483412 | ||||||||
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| Practice Location | |||||||||
| Address1: | 806 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127483412 | ||||||||
| FaxNumber: | 8127483413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2012 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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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 | 363LF0000X | 71004130A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201092460 | 05 | IN | MEDICAID | 000001079109 | 01 | IN | ANTHEM | OTHER | P01212103 | 01 | IN | RR MEDICARE PTAN | OTHER |