Provider Demographics
NPI:1083015788
Name:LITTELL, MELISSA (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LITTELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:
Practice Address - Street 1:17200 SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-4437
Practice Address - Country:US
Practice Address - Phone:810-714-9660
Practice Address - Fax:810-714-9661
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP20150004Medicare PIN