Provider Demographics
NPI:1215197116
Name:CONERLY, MELLISA SUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELLISA
Middle Name:SUE
Last Name:CONERLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MELLISA
Other - Middle Name:SUE
Other - Last Name:NOWAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4925 FLATHEAD PL
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-3583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4309 EMPEROR BLVD STE 125
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8068
Practice Address - Country:US
Practice Address - Phone:919-964-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant