Provider Demographics
NPI:1528082187
Name:MORENO, MELISSA W I (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:W
Last Name:MORENO
Suffix:I
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:WENTLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:80 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1332
Mailing Address - Country:US
Mailing Address - Phone:914-262-6216
Mailing Address - Fax:
Practice Address - Street 1:25 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:CONGERS
Practice Address - State:NY
Practice Address - Zip Code:10920-1401
Practice Address - Country:US
Practice Address - Phone:845-267-0110
Practice Address - Fax:845-267-2634
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF344757-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ7110Medicare UPIN