Provider Demographics
NPI:1346609773
Name:DEZAN, MELISSA R (MS, FNP-BC)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:R
Last Name:DEZAN
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:R
Other - Last Name:DEZAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, FNP-BC
Mailing Address - Street 1:1434 ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7925 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2128
Practice Address - Country:US
Practice Address - Phone:718-464-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-13
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY726454163W00000X
NY3209241164W00000X
NY350891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse