Provider Demographics
NPI:1063654911
Name:SMALL, MELANIE R (ANP-BC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:SMALL
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FODEN RD, WEST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SO PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:
Practice Address - Street 1:259 MAIN ST.
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096
Practice Address - Country:US
Practice Address - Phone:207-828-0361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081014363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner