Healthcare Provider Details

I. General information

NPI: 1295925956
Provider Name (Legal Business Name): MELANIE JEAN KOUMENTAKOS PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SILVER ST UNIT 106
AGAWAM MA
01001-3067
US

IV. Provider business mailing address

200 SILVER ST UNIT 106
AGAWAM MA
01001-3067
US

V. Phone/Fax

Practice location:
  • Phone: 413-341-5350
  • Fax: 413-341-5335
Mailing address:
  • Phone: 413-341-5350
  • Fax: 413-341-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001905
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: