Provider Demographics
NPI:1255564464
Name:HEINS, MELISSA MARIE (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:HEINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:CZAKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:237 ELM ST
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 YORK STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-688-2182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2309363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant