Provider Demographics
NPI:1295925956
Name:KOUMENTAKOS, MELANIE JEAN (PA C)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:JEAN
Last Name:KOUMENTAKOS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ELM ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-741-2225
Mailing Address - Fax:860-741-2229
Practice Address - Street 1:113 ELM ST
Practice Address - Street 2:SUITE 304
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-741-2225
Practice Address - Fax:860-741-2229
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant