Provider Demographics
NPI:1649442690
Name:MELLONIG, AMY K (AUDIOLOGIST)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:MELLONIG
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2808
Mailing Address - Country:US
Mailing Address - Phone:281-943-2790
Mailing Address - Fax:281-943-2773
Practice Address - Street 1:508 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:281-943-2790
Practice Address - Fax:281-943-2773
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51453231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152797002Medicaid
TX8K8746Medicare PIN