Provider Demographics
NPI:1598309270
Name:MELVIN, DANA (PFT)
Entity Type:Individual
Prefix:MR
First Name:DANA
Middle Name:
Last Name:MELVIN
Suffix:
Gender:M
Credentials:PFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 LOST LAKES DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6014
Mailing Address - Country:US
Mailing Address - Phone:678-637-8014
Mailing Address - Fax:
Practice Address - Street 1:639 METROMONT RD STE A
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2805
Practice Address - Country:US
Practice Address - Phone:678-637-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA694962174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator