Healthcare Provider Details

I. General information

NPI: 1255837407
Provider Name (Legal Business Name): MELISSA ANTONOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 COMMACK RD STE 100
COMMACK NY
11725-3457
US

IV. Provider business mailing address

6141 69TH PL
MIDDLE VILLAGE NY
11379-1126
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-8282
  • Fax:
Mailing address:
  • Phone: 917-922-7005
  • Fax: 917-922-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number631114
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF3822794-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF382794
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: