Provider Demographics
NPI:1417723826
Name:JOHN, MELODY ALLAINE
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:ALLAINE
Last Name:JOHN
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 1:124 SE 709TH ST
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32680-4027
Mailing Address - Country:US
Mailing Address - Phone:352-638-6765
Mailing Address - Fax:
Practice Address - Street 1:4400 N HIGHWAY 19A STE 12
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2022
Practice Address - Country:US
Practice Address - Phone:352-638-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46276225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty