Provider Demographics
NPI:1063784619
Name:GRAYBILL, MELANIE MARIE (IDC)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MARIE
Last Name:GRAYBILL
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 TIMBER VALLEY WAY
Mailing Address - Street 2:APT 114
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5456
Mailing Address - Country:US
Mailing Address - Phone:619-876-2767
Mailing Address - Fax:
Practice Address - Street 1:956 TIMBER VALLEY WAY
Practice Address - Street 2:APT 114
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5456
Practice Address - Country:US
Practice Address - Phone:619-876-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-29
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0115853851710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman