Healthcare Provider Details

I. General information

NPI: 1366565202
Provider Name (Legal Business Name): SUSAN BROWN MELNICK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 E MAIN ST
RIVERHEAD NY
11901-2613
US

IV. Provider business mailing address

883 E MAIN ST
RIVERHEAD NY
11901-2613
US

V. Phone/Fax

Practice location:
  • Phone: 631-284-5540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberF30082
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: