Provider Demographics
NPI:1528115755
Name:SUTTON, MELISSA A (ANP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:SUTTON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:BOTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 19036
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4085
Mailing Address - Country:US
Mailing Address - Phone:903-381-7272
Mailing Address - Fax:903-381-7269
Practice Address - Street 1:709 HOLLYBROOK DRIVE
Practice Address - Street 2:SUITE 2301
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2411
Practice Address - Country:US
Practice Address - Phone:903-757-4691
Practice Address - Fax:903-757-4875
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX657825363LP2300X
TXAP112666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165806403Medicaid
TXQ09071Medicare UPIN
TXTXB148196Medicare PIN