Provider Demographics
NPI:1861820193
Name:WANDELT, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:WANDELT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LABANOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:358 VETERANS HWY
Mailing Address - Street 2:STE. 11
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4326
Mailing Address - Country:US
Mailing Address - Phone:631-534-8844
Mailing Address - Fax:631-534-8840
Practice Address - Street 1:358 VETERANS HWY
Practice Address - Street 2:STE. 11
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4326
Practice Address - Country:US
Practice Address - Phone:631-534-8844
Practice Address - Fax:631-534-8840
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant