Provider Demographics
NPI:1376668087
Name:HALL, MELISSA DALE (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DALE
Last Name:HALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 KINGS RD
Mailing Address - Street 2:LOT B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5467
Mailing Address - Country:US
Mailing Address - Phone:904-501-5974
Mailing Address - Fax:
Practice Address - Street 1:2155 OLD MOULTRIE RD
Practice Address - Street 2:107
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5102
Practice Address - Country:US
Practice Address - Phone:904-501-5974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA22809225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7557Medicare UPIN