Provider Demographics
NPI:1073543468
Name:MCDONALD, MELORI (NP)
Entity Type:Individual
Prefix:
First Name:MELORI
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15945 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1147
Mailing Address - Country:US
Mailing Address - Phone:586-263-1818
Mailing Address - Fax:586-314-6044
Practice Address - Street 1:CHILDREN'S HOSPITAL OF MI
Practice Address - Street 2:3901 BEAUBIEN 4TH FLOOR CARL'S BLDG
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-5585
Practice Address - Fax:313-745-5155
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704175102363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION35280005Medicare PIN