Provider Demographics
NPI:1619239241
Name:FORNABIA, MELISSA MARIE (DOM)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:FORNABIA
Suffix:
Gender:F
Credentials:DOM
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 192331
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33119-2331
Mailing Address - Country:US
Mailing Address - Phone:203-994-0789
Mailing Address - Fax:
Practice Address - Street 1:900 MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-8480
Practice Address - Country:US
Practice Address - Phone:203-994-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3129171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist