=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083407761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA LEO
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 08/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1275 YORK AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-798-9213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1275 YORK AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-604-4275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 407043
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------