Provider Demographics
NPI:1295225266
Name:MADERA, MELLISSA
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:
Last Name:MADERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4914 IVY GLEN PL
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-6149
Mailing Address - Country:US
Mailing Address - Phone:727-452-5065
Mailing Address - Fax:
Practice Address - Street 1:8132 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-8571
Practice Address - Country:US
Practice Address - Phone:727-863-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant