Provider Demographics
NPI:1699263871
Name:BEATTY, MELONIE A
Entity type:Individual
Prefix:
First Name:MELONIE
Middle Name:A
Last Name:BEATTY
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 1:12133 BROOKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2931
Mailing Address - Country:US
Mailing Address - Phone:804-301-3178
Mailing Address - Fax:
Practice Address - Street 1:12133 BROOKVIEW DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2931
Practice Address - Country:US
Practice Address - Phone:804-301-3178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0175172615Medicaid