Basic Information
| Provider Information | |||||||||
| NPI: | 1245560242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROVOST | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIE BENNETT | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENNETT | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 165 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105624702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149411263 | ||||||||
| FaxNumber: | 9149418626 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105491910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146663272 | ||||||||
| FaxNumber: | 9149418626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2010 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 605446 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 336151 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.