Provider Demographics
NPI:1265640783
Name:BOERIO, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:BOERIO
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 1:5308 TIPTREE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203
Mailing Address - Country:US
Mailing Address - Phone:573-474-1054
Mailing Address - Fax:
Practice Address - Street 1:1316 OLD HIGHWAY 63 S
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6092
Practice Address - Country:US
Practice Address - Phone:573-445-4272
Practice Address - Fax:573-815-2477
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO135334363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO135334OtherSTATE LICENSE