Provider Demographics
NPI:1811500028
Name:DEANDRADE, MELLISA
Entity type:Individual
Prefix:MS
First Name:MELLISA
Middle Name:
Last Name:DEANDRADE
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 1:38 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3012
Mailing Address - Country:US
Mailing Address - Phone:617-960-6588
Mailing Address - Fax:
Practice Address - Street 1:38 WINTER ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3012
Practice Address - Country:US
Practice Address - Phone:617-960-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2337063163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health