Provider Demographics
NPI:1669776415
Name:MCMELLION, MARYELLEN
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:MCMELLION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 QUINCEY XING
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6385
Mailing Address - Country:US
Mailing Address - Phone:404-358-4354
Mailing Address - Fax:
Practice Address - Street 1:7111 FAIRWAY DR
Practice Address - Street 2:SUITE 450
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-4204
Practice Address - Country:US
Practice Address - Phone:561-623-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9322064367500000X
GARN168597163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9322064OtherARNP LICENSE