Healthcare Provider Details

I. General information

NPI: 1790804433
Provider Name (Legal Business Name): LISA MELVILLE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST SUITE 470
PROVIDENCE RI
02905-3236
US

IV. Provider business mailing address

PO BOX 16149
RUMFORD RI
02916-0697
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-1800
  • Fax: 401-868-2300
Mailing address:
  • Phone: 401-453-9625
  • Fax: 401-435-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPP37658
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number206157
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: