Provider Demographics
NPI:1013423193
Name:GROMACKI, MELISSA LEE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:GROMACKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FRANK SOTTILE BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1550
Mailing Address - Country:US
Mailing Address - Phone:845-336-2058
Mailing Address - Fax:845-336-2304
Practice Address - Street 1:601 FRANK SOTTILE BLVD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1550
Practice Address - Country:US
Practice Address - Phone:845-336-2058
Practice Address - Fax:845-336-2304
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008275156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician