Provider Demographics
NPI:1720717663
Name:RUSNACK, MELINDA ANN
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANN
Last Name:RUSNACK
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 1:305 OBERLIN RD UNIT 110
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-3160
Mailing Address - Country:US
Mailing Address - Phone:919-656-9516
Mailing Address - Fax:
Practice Address - Street 1:507 N BRIGHTLEAF BLVD STE 202
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4405
Practice Address - Country:US
Practice Address - Phone:919-791-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant