=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871858951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA FLACCAVENTO MAIETTA M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2012
-----------------------------------------------------
Last Update Date | 07/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 253 LAMPORT BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-991-9606
-----------------------------------------------------
Fax | 718-720-0173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 253 LAMPORT BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-991-9606
-----------------------------------------------------
Fax | 718-720-0173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 891798
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------