Provider Demographics
NPI:1093863300
Name:WALLENTIN, MELISSA ANN (RPA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WALLENTIN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:PEEDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:41-40 27TH STREET
Mailing Address - Street 2:C/O THE FLOATING HOSPITAL
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:718-784-2240
Mailing Address - Fax:718-784-0240
Practice Address - Street 1:41-40 27TH STREET
Practice Address - Street 2:C/O THE FLOATING HOSPITAL
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-784-2240
Practice Address - Fax:718-784-0240
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011550363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant