Provider Demographics
NPI:1093069742
Name:HAWTHORNE, MELISSA GAYLE (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GAYLE
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 NW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-1340
Mailing Address - Country:US
Mailing Address - Phone:352-231-1893
Mailing Address - Fax:904-239-3272
Practice Address - Street 1:607 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5449
Practice Address - Country:US
Practice Address - Phone:352-231-1893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68218225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist