Provider Demographics
NPI:1750415766
Name:DERBOGHOSSIAN, MELISSA (NP)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:
Last Name:DERBOGHOSSIAN
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 1:300 MERIDIAN CENTRE BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3981
Mailing Address - Country:US
Mailing Address - Phone:518-469-1064
Mailing Address - Fax:585-463-3105
Practice Address - Street 1:300 MERIDIAN CENTRE BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3981
Practice Address - Country:US
Practice Address - Phone:518-469-1064
Practice Address - Fax:585-463-3105
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF33041-1363LF0000X
NY334140363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily