Provider Demographics
NPI:1922178797
Name:ROMAN, MELISSA (APRN-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:22024 KNUDSEN DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1395
Mailing Address - Country:US
Mailing Address - Phone:313-916-7359
Mailing Address - Fax:313-916-9027
Practice Address - Street 1:39450 W 12 MILE RD FL 2
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3600
Practice Address - Country:US
Practice Address - Phone:313-916-7359
Practice Address - Fax:313-916-9027
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704221433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMR1193109OtherDEA