1407415789 NPI number — MELANIE SMALLEY STANISLAWSKI DO

Table of content: MELANIE SMALLEY STANISLAWSKI DO (NPI 1407415789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407415789 NPI number — MELANIE SMALLEY STANISLAWSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANISLAWSKI
Provider First Name:
MELANIE
Provider Middle Name:
SMALLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMALLEY
Provider Other First Name:
MELANIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407415789
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 MATTHEWS TOWNSHIP PKWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-5403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-384-6901
Provider Business Practice Location Address Fax Number:
704-384-6902
Provider Enumeration Date:
06/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  5151013533 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2024-01070 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114682300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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