Provider Demographics
NPI:1548219728
Name:MEMOLO, FAYE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:FAYE
Middle Name:
Last Name:MEMOLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 MAIN ST., APT. 6
Mailing Address - Street 2:NATIONAL DERMATOLOGY HEALTHCARE/FAYE MEMOLO, PA-C
Mailing Address - City:COLEBROOK
Mailing Address - State:NH
Mailing Address - Zip Code:03576
Mailing Address - Country:US
Mailing Address - Phone:603-348-0259
Mailing Address - Fax:
Practice Address - Street 1:187 MAIN ST
Practice Address - Street 2:APT. 6
Practice Address - City:COLEBROOK
Practice Address - State:NH
Practice Address - Zip Code:03576-2012
Practice Address - Country:US
Practice Address - Phone:603-348-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0403 P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH200999212OtherTAX ID
NH7058699OtherAETNA
VT00068486OtherBCBS OF VT
NH30333351Medicaid
VT9000213Medicaid
VT00068486OtherBCBS OF VT