Provider Demographics
NPI:1013426261
Name:REILLY, MELISSA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HARLOQUIN DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3310
Mailing Address - Country:US
Mailing Address - Phone:646-773-6281
Mailing Address - Fax:
Practice Address - Street 1:329 E MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2831
Practice Address - Country:US
Practice Address - Phone:631-366-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily