Provider Demographics
NPI:1528505070
Name:MELLOTT, KASSANDRA ALYSABETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:KASSANDRA
Middle Name:ALYSABETH
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-0217
Mailing Address - Country:US
Mailing Address - Phone:712-542-2176
Mailing Address - Fax:712-542-8311
Practice Address - Street 1:220 ESSIE DAVISON DR
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2915
Practice Address - Country:US
Practice Address - Phone:712-542-2176
Practice Address - Fax:712-542-8311
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE2237207Q00000X, 363A00000X
IA085452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine