Provider Demographics
NPI:1972828531
Name:MORDECAI, MELISSA (MSN, CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:MORDECAI
Suffix:
Gender:F
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 FRIES MILL RD STE 301
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:856-374-1881
Mailing Address - Fax:
Practice Address - Street 1:8025 BLACK HORSE PIKE STE 501
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-2967
Practice Address - Country:US
Practice Address - Phone:609-822-7979
Practice Address - Fax:609-822-7980
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP01082363LA2100X
NJ26NJ00376600363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0314595Medicaid