Provider Demographics
NPI:1093191868
Name:VUMBACA, MELANIE (LPTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:VUMBACA
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 S CLYDE MORRIS BLVD
Mailing Address - Street 2:STE.1D
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6404
Mailing Address - Country:US
Mailing Address - Phone:386-492-2986
Mailing Address - Fax:386-492-2987
Practice Address - Street 1:4606 S CLYDE MORRIS BLVD
Practice Address - Street 2:STE.1D
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6404
Practice Address - Country:US
Practice Address - Phone:386-492-2986
Practice Address - Fax:386-492-2987
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25780225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant