Healthcare Provider Details

I. General information

NPI: 1144368127
Provider Name (Legal Business Name): ANN F MELLEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13407 STATE ROUTE 12
BOONVILLE NY
13309
US

IV. Provider business mailing address

13407 STATE ROUTE 12
BOONVILLE NY
13309
US

V. Phone/Fax

Practice location:
  • Phone: 315-942-3500
  • Fax: 315-942-3618
Mailing address:
  • Phone: 315-942-3500
  • Fax: 315-942-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF331641
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF331641-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: