Basic Information
| Provider Information | |||||||||
| NPI: | 1821376740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELAMUD | ||||||||
| FirstName: | POLINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 CRANBROOK BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060823889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609626600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2011 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 004699 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 004699 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 004699 | 01 | CT | LICENSE | OTHER |