Provider Demographics
NPI:1689240038
Name:VAINE, MELISSA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:VAINE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1373
Mailing Address - Country:US
Mailing Address - Phone:978-630-6280
Mailing Address - Fax:
Practice Address - Street 1:242 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1373
Practice Address - Country:US
Practice Address - Phone:978-630-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2021031217363L00000X
MARN2286559363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner