Provider Demographics
NPI:1780013755
Name:BERTIAUX, MELISSA (CRNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BERTIAUX
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S 9TH ST
Mailing Address - Street 2:STE. 501
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 S 9TH ST
Practice Address - Street 2:STE. 501
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5125
Practice Address - Country:US
Practice Address - Phone:215-543-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-10
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013330363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology