Provider Demographics
NPI:1437375060
Name:FAYARD, MELANIE LYNNE (PT)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:LYNNE
Last Name:FAYARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7066
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7066
Mailing Address - Country:US
Mailing Address - Phone:228-875-4000
Mailing Address - Fax:228-975-4051
Practice Address - Street 1:11010 DAVID ST STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3481
Practice Address - Country:US
Practice Address - Phone:228-832-8327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3357225100000X
TX1165928225100000X
TN7043225100000X
ARPT2654225100000X
MO2004008250225100000X
ALPTH3977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist