Provider Demographics
NPI:1144368127
Name:MELLEN, ANN F (FNP)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:F
Last Name:MELLEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13407 STATE ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13309
Mailing Address - Country:US
Mailing Address - Phone:315-942-3500
Mailing Address - Fax:315-942-3618
Practice Address - Street 1:13407 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309
Practice Address - Country:US
Practice Address - Phone:315-942-3500
Practice Address - Fax:315-942-3618
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331641363LF0000X
NYF331641-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03300331641Medicaid
NYJ400072058Medicare PIN