Provider Demographics
NPI:1649356551
Name:BOOTHROYD, MELISSA SUSAN (PNP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:SUSAN
Last Name:BOOTHROYD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29085 OAK POINT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2715
Mailing Address - Country:US
Mailing Address - Phone:248-489-8632
Mailing Address - Fax:
Practice Address - Street 1:23200 RYAN RD
Practice Address - Street 2:FITZGERALD HEALTH CENTER
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-4551
Practice Address - Country:US
Practice Address - Phone:586-759-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704121618363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4667898Medicaid