Provider Demographics
NPI:1215640826
Name:MELLOR, JULIANA
Entity type:Individual
Prefix:
First Name:JULIANA
Middle Name:
Last Name:MELLOR
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 1:11 SHERI CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1163
Mailing Address - Country:US
Mailing Address - Phone:631-275-6153
Mailing Address - Fax:
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-548-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant