=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255837407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANTONOW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2018
-----------------------------------------------------
Last Update Date | 07/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 154 COMMACK RD STE 100
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725-3457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-499-8282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6141 69TH PL
-----------------------------------------------------
City | MIDDLE VILLAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11379-1126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-922-7005
-----------------------------------------------------
Fax | 917-922-7005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | F3822794-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | F382794
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 631114
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------