Provider Demographics
NPI:1528793387
Name:BOALS, MELODY CAMILLE
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:CAMILLE
Last Name:BOALS
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 1:150 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-1141
Mailing Address - Country:US
Mailing Address - Phone:330-399-6451
Mailing Address - Fax:
Practice Address - Street 1:150 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-1141
Practice Address - Country:US
Practice Address - Phone:330-399-6451
Practice Address - Fax:330-394-6266
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-17
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0033150363LP0808X
OHRN.343740163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health