Basic Information
| Provider Information | |||||||||
| NPI: | 1235787250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLARD | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 O AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687433072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128988391 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6120 MORNINGSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511063943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122763000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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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 | 225200000X | 01135 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.