Provider Demographics
NPI:1821376740
Name:MELAMUD, POLINA M (APRN)
Entity Type:Individual
Prefix:
First Name:POLINA
Middle Name:M
Last Name:MELAMUD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0253
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:9 CRANBROOK BLVD FL 2
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3889
Practice Address - Country:US
Practice Address - Phone:860-962-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004699363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004699OtherLICENSE