Provider Demographics
NPI:1588115513
Name:FICKEN, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FICKEN
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 1:12 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-2502
Mailing Address - Country:US
Mailing Address - Phone:631-953-1324
Mailing Address - Fax:
Practice Address - Street 1:263 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1224
Practice Address - Country:US
Practice Address - Phone:631-419-6737
Practice Address - Fax:631-868-3498
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326915-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse