Provider Demographics
NPI:1811541998
Name:MELLISH, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:MELLISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 CHASE LN UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508-1096
Mailing Address - Country:US
Mailing Address - Phone:360-742-6499
Mailing Address - Fax:
Practice Address - Street 1:55 CHASE LN UNIT 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-1096
Practice Address - Country:US
Practice Address - Phone:360-742-6499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-28
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer