Provider Demographics
NPI:1649573734
Name:SIMON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SIMON
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 1:6204 ROUTE 20A E
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-9309
Mailing Address - Country:US
Mailing Address - Phone:585-813-3045
Mailing Address - Fax:
Practice Address - Street 1:6204 ROUTE 20A E
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-9309
Practice Address - Country:US
Practice Address - Phone:585-813-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297175-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse