Provider Demographics
NPI:1003980384
Name:BOCK, MELISSA HINES (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:HINES
Last Name:BOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 WEST GARDEN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-255-6938
Mailing Address - Fax:315-253-4056
Practice Address - Street 1:37 WEST GARDEN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-255-6938
Practice Address - Fax:315-253-4056
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4593571163W00000X
NYF331298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01470144Medicaid