Basic Information
| Provider Information | |||||||||
| NPI: | 1518963073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PACKWOOD | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534917 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 3940 DUPONT CIR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028951111 | ||||||||
| FaxNumber: | 5028951085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA760 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 600673930W | 01 | KY | HUMANA | OTHER | 0701078 | 01 | KY | UNITED HEALTHCARE | OTHER | 50001576 | 01 | KY | PASSPORT | OTHER | P00466690 | 01 | KY | RR MEDICARE | OTHER | 95003711 | 05 | KY | MEDICAID |