Provider Demographics
NPI:1215273149
Name:TIBURCIO, MELIE SIMON (FNP)
Entity type:Individual
Prefix:MRS
First Name:MELIE
Middle Name:SIMON
Last Name:TIBURCIO
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Gender:F
Credentials:FNP
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Mailing Address - Street 1:PO BOX 27036
Mailing Address - Street 2:NEW YORK
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7036
Mailing Address - Country:US
Mailing Address - Phone:212-342-3892
Mailing Address - Fax:212-342-5262
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:MHB 7-435 GN
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-6003
Practice Address - Fax:212-305-0907
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2018-04-30
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Provider Licenses
StateLicense IDTaxonomies
NY7607314363LF0000X
NYF337011-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3543304Medicaid
NY3543304Medicaid