Provider Demographics
NPI:1881051522
Name:MCMACKIN, MELISSA (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCMACKIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E HARPER ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:TN
Mailing Address - Zip Code:38260-5951
Mailing Address - Country:US
Mailing Address - Phone:731-536-4624
Mailing Address - Fax:731-536-4905
Practice Address - Street 1:316 E HARPER ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:TN
Practice Address - Zip Code:38260-5951
Practice Address - Country:US
Practice Address - Phone:731-536-4624
Practice Address - Fax:731-536-4905
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20918363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner