Provider Demographics
NPI:1710499017
Name:TULLY, MELISSA (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BEAN CT
Mailing Address - Street 2:
Mailing Address - City:WANAQUE
Mailing Address - State:NJ
Mailing Address - Zip Code:07465-1001
Mailing Address - Country:US
Mailing Address - Phone:973-207-8426
Mailing Address - Fax:
Practice Address - Street 1:60 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RINGWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07456-2039
Practice Address - Country:US
Practice Address - Phone:973-962-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00755400363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health