MEDICARE: CLARISSA MELLON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703020477	MI

General Provider Information

NPI Number	:	1477019636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA MELLON

Provider Business Mailing Address
First Line	:	8033 E 10 MILE RD STE 114
Second Line	:
City	:	CENTER LINE
State	:	MI
Zip	:	48015-1454
Country	:	US
Telephone Number	:	586-756-6661
Fax Number	:	586-756-6933

Provider Business Practice Location Address
First Line	:	1902 STAR BATT DR
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-3711
Country	:	US
Telephone Number	:	248-844-9650
Fax Number	:	248-844-9651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	01/04/2026

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