Provider Demographics
NPI:1225658065
Name:NAZARENO, MELANIE MANDABON
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:MANDABON
Last Name:NAZARENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 WOODLAND DR STE D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1737
Mailing Address - Country:US
Mailing Address - Phone:317-286-2885
Mailing Address - Fax:317-536-3097
Practice Address - Street 1:22 E 49TH ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-1097
Practice Address - Country:US
Practice Address - Phone:212-832-9127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist