Provider Demographics
NPI:1699088310
Name:DAMUTH, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DAMUTH
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 1:6670 STATE ROUTE 294
Mailing Address - Street 2:APT 1
Mailing Address - City:AVA
Mailing Address - State:NY
Mailing Address - Zip Code:13303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6670 STATE ROUTE 294
Practice Address - Street 2:APT 1
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309-3957
Practice Address - Country:US
Practice Address - Phone:315-942-2849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280476164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse