Provider Demographics
NPI:1285277467
Name:MELTON, SHAMIKA
Entity type:Individual
Prefix:
First Name:SHAMIKA
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 1:6316 OAK MIDDLE CT APT 304
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-4870
Mailing Address - Country:US
Mailing Address - Phone:804-972-6412
Mailing Address - Fax:
Practice Address - Street 1:6316 OAK MIDDLE CT APT 304
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-4870
Practice Address - Country:US
Practice Address - Phone:804-972-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA82-1639706Medicaid