Provider Demographics
NPI:1518533389
Name:MCCLARY, MELISSA BERNETTA
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:BERNETTA
Last Name:MCCLARY
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 1:123 DIVISION ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2137
Mailing Address - Country:US
Mailing Address - Phone:203-850-4288
Mailing Address - Fax:
Practice Address - Street 1:311 EAST ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5838
Practice Address - Country:US
Practice Address - Phone:203-562-2101
Practice Address - Fax:203-562-2102
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT34496164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse