Provider Demographics
NPI:1285910653
Name:CLARK, MELINDA LEE (AOCNP, ACNP/FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:AOCNP, ACNP/FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 HIGHWAY 182 W
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-9820
Mailing Address - Country:US
Mailing Address - Phone:662-320-8545
Mailing Address - Fax:662-320-8981
Practice Address - Street 1:1205 HIGHWAY 182 W
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-9820
Practice Address - Country:US
Practice Address - Phone:662-320-8545
Practice Address - Fax:662-320-8981
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR811185363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care