Basic Information
| Provider Information | |||||||||
| NPI: | 1669436853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSKIN | ||||||||
| FirstName: | MELODY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALE | ||||||||
| OtherFirstName: | MELODY | ||||||||
| OtherMiddleName: | H. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 176 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | 3044386819 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W. OYLER AVENUE | ||||||||
| Address2: | OAK HILL HIGH SCHOOL | ||||||||
| City: | OAK HILL | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044692905 | ||||||||
| FaxNumber: | 3044696332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 57241 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3810005940 | 05 | WV | MEDICAID |