Provider Demographics
NPI:1407117294
Name:MELLUSO-RUBY, ROSEANN (MSED)
Entity Type:Individual
Prefix:MRS
First Name:ROSEANN
Middle Name:
Last Name:MELLUSO-RUBY
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SOUTH AVE
Mailing Address - Street 2:LL2
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3409
Mailing Address - Country:US
Mailing Address - Phone:718-477-0961
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:LL2
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3409
Practice Address - Country:US
Practice Address - Phone:718-477-0961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1809755174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist