Provider Demographics
NPI:1275040016
Name:ELLENBERG, MELANIE TUCKER
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:TUCKER
Last Name:ELLENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:RENAE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:705 S BRADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-3417
Mailing Address - Country:US
Mailing Address - Phone:804-627-2819
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2536
Practice Address - Country:US
Practice Address - Phone:412-647-3260
Practice Address - Fax:412-647-6290
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA118724367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered