Provider Demographics
NPI:1285060566
Name:TILETNICK, MELISSA (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:TILETNICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-303-7283
Practice Address - Fax:407-303-0347
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006162363A00000X
NE2229363A00000X
TXPA11020363A00000X
NY016971-1363A00000X
FLPA9111177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4NMYGOtherBLUE CROSS BLUE SHIELD
FL100676300Medicaid