Provider Demographics
NPI:1952312720
Name:DOLESE, MELANIE ANN (ACNP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:DOLESE
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:L
Other - Last Name:TEJEDOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5520
Mailing Address - Country:US
Mailing Address - Phone:985-646-5627
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5520
Practice Address - Country:US
Practice Address - Phone:985-646-5627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR856944363L00000X
LAAP04922363L00000X
LARN063398363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02425360Medicaid
LA2152866Medicaid
MS500002674Medicare PIN
MS512I500632Medicare PIN
LA3B442DL36Medicare PIN
MS02425360Medicaid