Provider Demographics
NPI:1508289430
Name:MELLICK, BRAUNDA (LPN)
Entity Type:Individual
Prefix:
First Name:BRAUNDA
Middle Name:
Last Name:MELLICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-4951
Mailing Address - Country:US
Mailing Address - Phone:810-434-1644
Mailing Address - Fax:
Practice Address - Street 1:920 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-4951
Practice Address - Country:US
Practice Address - Phone:810-434-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703049729164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse