Provider Demographics
NPI:1871056721
Name:ROSS WADDY, MELISSA ELAINE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ELAINE
Last Name:ROSS WADDY
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 1:259 PETER JONE HILL RD
Mailing Address - Street 2:
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086-3133
Mailing Address - Country:US
Mailing Address - Phone:804-769-9237
Mailing Address - Fax:
Practice Address - Street 1:8359 SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2327
Practice Address - Country:US
Practice Address - Phone:804-787-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62932972172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver