Provider Demographics
NPI:1942245253
Name:MELTON, CONNIE ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:ANN
Last Name:MELTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:IN
Mailing Address - Zip Code:47231-0087
Mailing Address - Country:US
Mailing Address - Phone:812-273-3737
Mailing Address - Fax:
Practice Address - Street 1:1025 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2823
Practice Address - Country:US
Practice Address - Phone:502-584-2473
Practice Address - Fax:502-657-0228
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA152363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50006904Medicaid
KY50006904Medicaid