Provider Demographics
NPI:1043459696
Name:MERRILL, MELISSA D (CNM, WHNP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:D
Last Name:MERRILL
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:VITEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1825
Mailing Address - Country:US
Mailing Address - Phone:208-324-5286
Mailing Address - Fax:208-324-9815
Practice Address - Street 1:132 5TH AVE W
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1825
Practice Address - Country:US
Practice Address - Phone:208-324-5286
Practice Address - Fax:208-324-9815
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID19862A367A00000X
IDNP1172A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010171795OtherBS
ID808284700Medicaid
IDNP311OtherBC
IDNP311OtherBC