Basic Information
| Provider Information | |||||||||
| NPI: | 1275904021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 732 HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | FRENCHBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403228123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067682191 | ||||||||
| FaxNumber: | 6067686130 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 FOUNTAIN CT FL 1 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405092792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592182626 | ||||||||
| FaxNumber: | 8592573322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2015 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3009795 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3009795 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | K197590 | 01 | KY | MEDICARE | OTHER | 7100386170 | 05 | KY | MEDICAID | 3009795 | 01 | KY | MEDICAL LICENSE | OTHER |