Provider Demographics
NPI:1750671939
Name:MACKINNON, MELISSA CAROLYN (RN)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CAROLYN
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:CAROLYN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1382 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2129
Mailing Address - Country:US
Mailing Address - Phone:857-498-2396
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:617-323-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2269989163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse