Provider Demographics
NPI:1326639493
Name:INGRAHAM PICKENS, MELISSA VASTORIA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:VASTORIA
Last Name:INGRAHAM PICKENS
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 1:10945 S. BUFFALO AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617
Mailing Address - Country:US
Mailing Address - Phone:312-834-1454
Mailing Address - Fax:
Practice Address - Street 1:10945 S. BUFFALO AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:312-834-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide