Healthcare Provider Details

I. General information

NPI: 1912722323
Provider Name (Legal Business Name): MELISSA LEE KUHLEN GILLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

67 AUTUMN LN
LEVITTOWN PA
19055-1232
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-7272
  • Fax:
Mailing address:
  • Phone: 856-381-5475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA066172
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: