Provider Demographics
NPI:1225819915
Name:MUTRIE, MELISSA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICOLE
Last Name:MUTRIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KETTLE POINT AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 ROCHE BROS WAY STE 200
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1000
Practice Address - Country:US
Practice Address - Phone:781-344-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA100181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant