Basic Information
| Provider Information | |||||||||
| NPI: | 1760834808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTAMIRANO | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHAMPION | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 490 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287218026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286924289 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 490 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287218026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286924289 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 830190 | TX | N | Nursing Service Providers | Registered Nurse | 163W00000X | 341924 | NC | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP131277 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 5015886 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.