Provider Demographics
NPI:1487961504
Name:WAX, MELINDA SUSAN (RN)
Entity type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:SUSAN
Last Name:WAX
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 MISSOURI AVE.
Mailing Address - Street 2:MEDDAC , CHRC , BOX 1229
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8952
Mailing Address - Country:US
Mailing Address - Phone:573-329-1901
Mailing Address - Fax:
Practice Address - Street 1:199 EAST 4TH STREET
Practice Address - Street 2:BUILDING 2081, SUITE H.
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-329-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000154973163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse