Provider Demographics
NPI:1225003502
Name:MELLON, LYSE MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:LYSE
Middle Name:MARIE
Last Name:MELLON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 BOGGY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-9516
Mailing Address - Country:US
Mailing Address - Phone:407-343-2088
Mailing Address - Fax:407-343-2069
Practice Address - Street 1:1875 BOGGY CREEK RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-9516
Practice Address - Country:US
Practice Address - Phone:407-943-7011
Practice Address - Fax:407-343-2067
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1263081164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse