Provider Demographics
NPI:1548902141
Name:BALLOU, MELISSA EMILY (RN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:EMILY
Last Name:BALLOU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:EMILY
Other - Last Name:MACTAVISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4705 OLD POST RD UNIT A
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-1842
Practice Address - Country:US
Practice Address - Phone:401-364-7705
Practice Address - Fax:401-364-1982
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN63724163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse