Provider Demographics
NPI:1043532864
Name:PENNANT, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PENNANT
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 1:189 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4903
Mailing Address - Country:US
Mailing Address - Phone:718-809-9685
Mailing Address - Fax:718-228-7059
Practice Address - Street 1:189 BEECH ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4903
Practice Address - Country:US
Practice Address - Phone:718-809-9685
Practice Address - Fax:718-228-7059
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-20
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298786164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06335780Medicaid