Provider Demographics
NPI:1417143397
Name:MELINO, SUSAN SLOCUM (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:SLOCUM
Last Name:MELINO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-1764
Mailing Address - Country:US
Mailing Address - Phone:973-377-7122
Mailing Address - Fax:
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:186-638-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333673-1364SF0001X
NJ26NJ00145700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily