Healthcare Provider Details

I. General information

NPI: 1649571175
Provider Name (Legal Business Name): MELISSA ANNE SMITH MSN, APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA ANNE BOISSELLE MSN, APN

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S CHURCH ST STE 18
MOUNT LAUREL NJ
08054-2936
US

IV. Provider business mailing address

1200 S CHURCH ST STE 18
MOUNT LAUREL NJ
08054-2936
US

V. Phone/Fax

Practice location:
  • Phone: 856-639-6500
  • Fax: 856-329-7827
Mailing address:
  • Phone: 856-639-6500
  • Fax: 856-329-7827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01009500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number26NR12116300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number26NR12116300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: