Provider Demographics
NPI:1356406847
Name:MELVIN, CHARLES H (APRN)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:MELVIN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:ATTN: CREDENTIALING DPT
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2718
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:860-704-8034
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-400885363LP0808X
CT004673363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02837850Medicaid
CT004236338Medicaid
90V12EX661Medicare PIN
NY02837850Medicaid