Provider Demographics
NPI:1629580154
Name:MELNICK, SAMANTHA JILL (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JILL
Last Name:MELNICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVENUE, 3RD FL
Practice Address - Street 2:MOAKLEY BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6428
Practice Address - Fax:617-638-5756
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2320171163W00000X, 363L00000X
MARN2320171363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner