Provider Demographics
NPI:1770582249
Name:GAGNON, MELANIE ANNE (PT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANNE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 EAST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1849
Mailing Address - Country:US
Mailing Address - Phone:717-514-1057
Mailing Address - Fax:
Practice Address - Street 1:436 EAST ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1849
Practice Address - Country:US
Practice Address - Phone:717-514-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008447L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01840210Medicaid
PA251844378OtherDEVON HEALTH SERVICES
PA650021545OtherRAILROAD MEDICARE
PAGA920917OtherHIGHMARK BLUE SHIELD
PA1537903OtherGATEWAY
PA2584842OtherAETNA US HEALTHCARE HMO
PA7911276OtherAETNA US HEALTHCARE PPO
PA20036904OtherAMERIHEALTH MERCY
PA02202001OtherCAPITAL BLUE CROSS
PA2584842OtherAETNA US HEALTHCARE HMO
PA1537903OtherGATEWAY