Provider Demographics
NPI:1164044814
Name:RUDISILL, MELINDA VINSON (RDN)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:VINSON
Last Name:RUDISILL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 MOUNT CARMEL LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-6707
Mailing Address - Country:US
Mailing Address - Phone:321-750-7226
Mailing Address - Fax:
Practice Address - Street 1:4105 NORFOLK PKWY
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8626
Practice Address - Country:US
Practice Address - Phone:321-750-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered