Provider Demographics
NPI:1710140793
Name:MATTIMORE, MELISSA DIANE I (RN, ACNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:MATTIMORE
Suffix:I
Gender:F
Credentials:RN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 5TH AVE
Mailing Address - Street 2:BOX 1458
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6503
Mailing Address - Country:US
Mailing Address - Phone:917-538-2769
Mailing Address - Fax:
Practice Address - Street 1:1190 5TH AVE
Practice Address - Street 2:BOX 1458
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6503
Practice Address - Country:US
Practice Address - Phone:917-538-2769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430405-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care