Provider Demographics
NPI:1871849034
Name:FAWBUSH, MELINDA WHEELEY (MSN, ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:WHEELEY
Last Name:FAWBUSH
Suffix:
Gender:F
Credentials:MSN, ARNP
Other - Prefix:MISS
Other - First Name:MELINDA
Other - Middle Name:KAY
Other - Last Name:WHEELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1235 SAN MARCO BLVD
Mailing Address - Street 2:#419
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8554
Mailing Address - Country:US
Mailing Address - Phone:904-202-7313
Mailing Address - Fax:904-202-7010
Practice Address - Street 1:1235 SAN MARCO BLVD
Practice Address - Street 2:#419
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8554
Practice Address - Country:US
Practice Address - Phone:904-202-7313
Practice Address - Fax:904-202-7010
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL828782363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health