Provider Demographics
NPI:1710344981
Name:MAYBURY, MELISSA (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MAYBURY
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 1:1101 JACKSON ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-9121
Mailing Address - Country:US
Mailing Address - Phone:479-787-5291
Mailing Address - Fax:479-344-6404
Practice Address - Street 1:1101 JACKSON ST SW
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-9121
Practice Address - Country:US
Practice Address - Phone:479-787-5291
Practice Address - Fax:479-344-6720
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004614363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner