Provider Demographics
NPI:1871238147
Name:MELENDEZ, MAKEBA L
Entity Type:Individual
Prefix:
First Name:MAKEBA
Middle Name:L
Last Name:MELENDEZ
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 1:1420 BLUE MAGNOLIA RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4018
Mailing Address - Country:US
Mailing Address - Phone:315-286-1461
Mailing Address - Fax:
Practice Address - Street 1:6450 38TH AVE N STE 120
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1649
Practice Address - Country:US
Practice Address - Phone:727-317-3767
Practice Address - Fax:727-317-5504
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9435781363LF0000X
FLAPRN11018561363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily