Provider Demographics
NPI:1912678061
Name:DALEY, MELONIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:
Last Name:DALEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9802
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-415-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY705899163W00000X
NYF349618-01363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner