Provider Demographics
NPI:1578222972
Name:PAULOSE, MELBA (NP)
Entity Type:Individual
Prefix:MRS
First Name:MELBA
Middle Name:
Last Name:PAULOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 5TH PL
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3605
Mailing Address - Country:US
Mailing Address - Phone:516-967-3681
Mailing Address - Fax:
Practice Address - Street 1:194-44 WOODHULL AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS, QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11423
Practice Address - Country:US
Practice Address - Phone:516-967-3681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310011-01363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF310011-01Medicaid