Provider Demographics
NPI:1639042401
Name:CAUDILL, MELINDA RENEE
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:RENEE
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 BLUE JAY CT
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-6289
Mailing Address - Country:US
Mailing Address - Phone:606-776-2536
Mailing Address - Fax:
Practice Address - Street 1:80 BLUE JAY CT
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-6289
Practice Address - Country:US
Practice Address - Phone:606-776-2536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No175T00000XOther Service ProvidersPeer Specialist