Provider Demographics
NPI:1114935830
Name:NELSON, MELANIE M (PHD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:D
Other - Last Name:MCDIARMID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:GLEN ST MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32040-0606
Mailing Address - Country:US
Mailing Address - Phone:904-653-1818
Mailing Address - Fax:904-653-1814
Practice Address - Street 1:871 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0433
Practice Address - Country:US
Practice Address - Phone:386-438-8615
Practice Address - Fax:386-438-8614
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1027103TC0700X
FLPY 8562103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHY549ZMedicare PIN