Basic Information
| Provider Information | |||||||||
| NPI: | 1922362052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUASSABA | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BC-ACNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 890 W FARIS RD STE 580 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644557874 | ||||||||
| FaxNumber: | 8644558933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2012 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 23210 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 364SA2200X | 209009613 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | NP6225 | 05 | SC | MEDICAID |