Provider Demographics
NPI:1629496682
Name:MELTON, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MELTON
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 1:2904 E GADSDEN ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-6429
Mailing Address - Country:US
Mailing Address - Phone:850-602-3826
Mailing Address - Fax:
Practice Address - Street 1:104 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3915
Practice Address - Country:US
Practice Address - Phone:850-602-3826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-06
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8525235Z00000X
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist