Provider Demographics
NPI:1487246278
Name:BALDWIN, MELISSA BROOKE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:BROOKE
Last Name:BALDWIN
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 1:18 CORPORATE HILL DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4565
Mailing Address - Country:US
Mailing Address - Phone:501-224-1156
Mailing Address - Fax:
Practice Address - Street 1:18 CORPORATE HILL DR STE 110
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4565
Practice Address - Country:US
Practice Address - Phone:501-224-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR214741363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214741Medicaid