Provider Demographics
NPI:1083971493
Name:BREAULT, MELISSA ANN (FNP)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:ANN
Last Name:BREAULT
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:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:258 HOOSICK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2427
Practice Address - Country:US
Practice Address - Phone:518-274-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336764-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily