Provider Demographics
NPI:1235506148
Name:VILLANUEVA, MELISSA JEANETTE
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:JEANETTE
Last Name:VILLANUEVA
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 1:74 DROVERS LN
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-2722
Mailing Address - Country:US
Mailing Address - Phone:845-612-3457
Mailing Address - Fax:
Practice Address - Street 1:226 LINDA AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2018
Practice Address - Country:US
Practice Address - Phone:914-773-7467
Practice Address - Fax:914-773-7341
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYED12983MMedicaid
NY132382571C3Medicare PIN