Provider Demographics
NPI:1215470257
Name:FACKLER, MELISSA (MSN, RN, CCRN FNP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:FACKLER
Suffix:
Gender:F
Credentials:MSN, RN, CCRN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 NORTHERN BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3013
Mailing Address - Country:US
Mailing Address - Phone:516-482-3401
Mailing Address - Fax:
Practice Address - Street 1:1350 NORTHERN BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030
Practice Address - Country:US
Practice Address - Phone:516-482-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687779-1363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse