Healthcare Provider Details

I. General information

NPI: 1164254074
Provider Name (Legal Business Name): MELANIE GROSSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

V. Phone/Fax

Practice location:
  • Phone: 631-316-0538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN334313
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: