Provider Demographics
NPI:1871858951
Name:FLACCAVENTO MAIETTA, MELISSA (MS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:FLACCAVENTO MAIETTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 LAMPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3503
Mailing Address - Country:US
Mailing Address - Phone:917-991-9606
Mailing Address - Fax:718-720-0173
Practice Address - Street 1:253 LAMPORT BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3503
Practice Address - Country:US
Practice Address - Phone:917-991-9606
Practice Address - Fax:718-720-0173
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY891798174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist