Provider Demographics
NPI:1578815015
Name:FORMAN, MELANIE GAY (ANP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:GAY
Last Name:FORMAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1520
Mailing Address - Country:US
Mailing Address - Phone:516-451-9355
Mailing Address - Fax:
Practice Address - Street 1:558 ARLINGTON PL
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1006
Practice Address - Country:US
Practice Address - Phone:516-444-9940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304843-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health