Provider Demographics
NPI:1255491288
Name:JOANNOW, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:JOANNOW
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 1:2605 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3124
Mailing Address - Country:US
Mailing Address - Phone:718-204-6932
Mailing Address - Fax:
Practice Address - Street 1:2605 23RD AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3124
Practice Address - Country:US
Practice Address - Phone:718-204-6932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01586910Medicaid
NY01586910Medicaid
NYE73076Medicare UPIN