Provider Demographics
NPI:1477019636
Name:MELLON, CLARISSA
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:MELLON
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 1:8033 E 10 MILE RD STE 114
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1454
Mailing Address - Country:US
Mailing Address - Phone:586-756-6661
Mailing Address - Fax:586-756-6933
Practice Address - Street 1:1902 STAR BATT DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3711
Practice Address - Country:US
Practice Address - Phone:248-844-9650
Practice Address - Fax:248-844-9651
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703020477164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse