Provider Demographics
NPI:1477898443
Name:HARRISON, MELINDA (RN, BSN, IBCLC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 BIG MAGNOLIA CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-1700
Mailing Address - Country:US
Mailing Address - Phone:904-823-6013
Mailing Address - Fax:
Practice Address - Street 1:320 HIGH TIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-2323
Practice Address - Country:US
Practice Address - Phone:904-823-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1792962163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant