Provider Demographics
NPI:1467963892
Name:RUSTERUCCI, MELISSA DIANE (AGNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:RUSTERUCCI
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GENEVIEVE CT
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4868
Mailing Address - Country:US
Mailing Address - Phone:770-486-1818
Mailing Address - Fax:
Practice Address - Street 1:100 GENEVIEVE CT
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4868
Practice Address - Country:US
Practice Address - Phone:770-486-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN215911363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN215911OtherSTATE LICENSE