Provider Demographics
NPI:1174900989
Name:TEOLI, MELISSA ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:TEOLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:KLOOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:19374 SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4106
Mailing Address - Country:US
Mailing Address - Phone:248-345-1654
Mailing Address - Fax:
Practice Address - Street 1:255 TERRACIHA BLVD SUITE 101A
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-748-6569
Practice Address - Fax:909-307-1231
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007346363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical