Provider Demographics
NPI:1033698121
Name:MELILLI, LAURA RUTH (LPN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:RUTH
Last Name:MELILLI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 WAVE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1753
Mailing Address - Country:US
Mailing Address - Phone:631-905-5073
Mailing Address - Fax:
Practice Address - Street 1:1211 WAVE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1753
Practice Address - Country:US
Practice Address - Phone:631-905-5073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132686-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse