1124463112 NPI number — MELANIE DAVIS WEATHERSPOON

Table of content: MELANIE DAVIS WEATHERSPOON (NPI 1124463112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124463112 NPI number — MELANIE DAVIS WEATHERSPOON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEATHERSPOON
Provider First Name:
MELANIE
Provider Middle Name:
DAVIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1124463112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1714 52ND TER SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34116-5652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-352-6629
Provider Business Mailing Address Fax Number:
239-455-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1714 52ND TER SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34116-5652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-352-6629
Provider Business Practice Location Address Fax Number:
239-455-7757
Provider Enumeration Date:
05/03/2013

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: 311ZA0620X , with the licence number:  004211600 , 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: 004211600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com