Provider Demographics
NPI:1649782640
Name:SMALLRIDGE, MARIA MELODY S (NP)
Entity type:Individual
Prefix:
First Name:MARIA MELODY
Middle Name:S
Last Name:SMALLRIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MCARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1924
Mailing Address - Country:US
Mailing Address - Phone:917-578-6492
Mailing Address - Fax:
Practice Address - Street 1:622 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1821
Practice Address - Country:US
Practice Address - Phone:732-829-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308374-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health