1689796518 NPI number — MELISSA KIM DEVAUGHN FNP-BC

Table of content: MELISSA KIM DEVAUGHN FNP-BC (NPI 1689796518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689796518 NPI number — MELISSA KIM DEVAUGHN FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEVAUGHN
Provider First Name:
MELISSA
Provider Middle Name:
KIM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689796518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 E SILVER SPRINGS BLVD
Provider Second Line Business Mailing Address:
#201
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34470-6831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-318-1487
Provider Business Mailing Address Fax Number:
352-384-7975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 E SILVER SPRINGS BLVD
Provider Second Line Business Practice Location Address:
#226
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34470-6831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-547-1596
Provider Business Practice Location Address Fax Number:
352-336-1771
Provider Enumeration Date:
04/04/2007

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: 363LP2300X , with the licence number:  ARNP2524142 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 303949800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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