Provider Demographics
NPI:1154052132
Name:MARK, MELISSA ANN (RN, BSN, CCM)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MARK
Suffix:
Gender:F
Credentials:RN, BSN, CCM
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, BSN, LCDC III
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0749
Mailing Address - Country:US
Mailing Address - Phone:740-649-1593
Mailing Address - Fax:
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9718
Practice Address - Country:US
Practice Address - Phone:740-649-1593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH336656163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health