Healthcare Provider Details

I. General information

NPI: 1083407761
Provider Name (Legal Business Name): MELISSA LEO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 08/07/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

1275 YORK AVE
NEW YORK NY
10065-6007
US

V. Phone/Fax

Practice location:
  • Phone: 347-798-9213
  • Fax:
Mailing address:
  • Phone: 213-604-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: