Basic Information
| Provider Information | |||||||||
| NPI: | 1831446863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3690 SANDBURG DR | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445111116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307938585 | ||||||||
| FaxNumber: | 3307938585 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445021037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307442991 | ||||||||
| FaxNumber: | 3307440887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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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 | 364SA2200X | COA 13241-NS | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363LP0808X | 2014034208 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0241705 | 05 | OH | MEDICAID |