Provider Demographics
NPI:1356855142
Name:FILLMORE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FILLMORE
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 1:45 OLD BARNABAS RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1947
Mailing Address - Country:US
Mailing Address - Phone:203-687-9430
Mailing Address - Fax:
Practice Address - Street 1:800 CROSS RIVER RD
Practice Address - Street 2:
Practice Address - City:KATONAH
Practice Address - State:NY
Practice Address - Zip Code:10536-3549
Practice Address - Country:US
Practice Address - Phone:914-763-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.428291163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent