Provider Demographics
NPI:1114439510
Name:PETERS, MELISSA FAY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:FAY
Last Name:PETERS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 OHIO AVE S
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4156
Mailing Address - Country:US
Mailing Address - Phone:386-364-0776
Mailing Address - Fax:386-364-1211
Practice Address - Street 1:1304 OHIO AVE S
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4156
Practice Address - Country:US
Practice Address - Phone:386-364-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9291513363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner