Healthcare Provider Details

I. General information

NPI: 1174957781
Provider Name (Legal Business Name): MELISSA BRUBAKER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 PRESIDENTIAL BLVD STE W3
BALA CYNWYD PA
19004-1205
US

IV. Provider business mailing address

191 PRESIDENTIAL BLVD STE W3
BALA CYNWYD PA
19004-1205
US

V. Phone/Fax

Practice location:
  • Phone: 215-550-1614
  • Fax: 445-201-3851
Mailing address:
  • Phone: 215-550-1614
  • Fax: 445-201-3851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP020670
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: