Provider Demographics
NPI:1023291580
Name:SCHNACKENBERG, MELINDA VAUGHAN (RTR(CV))
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:VAUGHAN
Last Name:SCHNACKENBERG
Suffix:
Gender:F
Credentials:RTR(CV)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 TREASURE CAY DR
Mailing Address - Street 2:208
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-5386
Mailing Address - Country:US
Mailing Address - Phone:904-806-4178
Mailing Address - Fax:
Practice Address - Street 1:700 TREASURE CAY DR
Practice Address - Street 2:208
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-5386
Practice Address - Country:US
Practice Address - Phone:904-806-4178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00-9371246XC2901X
FL290492471C1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C1101XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiovascular-Interventional Technology
No246XC2901XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularCardiovascular Invasive Specialist