Provider Demographics
NPI:1225529456
Name:MELTON, PENNY
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:MELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 E BAY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1399
Mailing Address - Country:US
Mailing Address - Phone:810-208-7080
Mailing Address - Fax:
Practice Address - Street 1:GHS-1040 WEST BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-701-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276828163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse