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General NPI Number Information
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NPI Number | 1225535453
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Entity Type | Individual
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Provider Name | MICHELLE MELLILO
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Gender | Female
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Dates
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Enumeration Date | 04/13/2018
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Last Update Date | 04/13/2018
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Provider Practice Location Address
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Address Line | 12 BALSAM LN
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City | LEVITTOWN
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State | NY
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Zip | 11756-4802
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Country | US
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Telephone | 631-987-5482
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Fax |
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Provider Business Mailing Address
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Address Line | 12 BALSAM LN
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City | LEVITTOWN
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State | NY
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Zip | 11756-4802
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Country | US
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Telephone | 631-987-5482
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 964001151
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License Number State | NY
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