Healthcare Provider Details

I. General information

NPI: 1174788921
Provider Name (Legal Business Name): MELISSA ANNE MAGNOLIA AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E 14TH ST AUDIOLOGY DEPT
NEW YORK NY
10003-4201
US

IV. Provider business mailing address

310 E 14TH ST AUDIOLOGY DEPT
NEW YORK NY
10003-4201
US

V. Phone/Fax

Practice location:
  • Phone: 212-979-4340
  • Fax: 212-533-3489
Mailing address:
  • Phone: 212-979-4340
  • Fax: 212-533-3489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number001870-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: