Provider Demographics
NPI:1972276285
Name:MESIDOR, VALESSA
Entity type:Individual
Prefix:
First Name:VALESSA
Middle Name:
Last Name:MESIDOR
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 1:32 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2606
Mailing Address - Country:US
Mailing Address - Phone:516-921-5910
Mailing Address - Fax:
Practice Address - Street 1:1400 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2257
Practice Address - Country:US
Practice Address - Phone:516-308-7405
Practice Address - Fax:516-308-7404
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347927-01363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY347927OtherSTATE LICENSE
NY06885978Medicaid
NYA400330312OtherMEDICARE