Provider Demographics
NPI:1356989156
Name:SCULLY, MELISSA RACHEL
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:RACHEL
Last Name:SCULLY
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-868-5833
Mailing Address - Fax:
Practice Address - Street 1:699 W COCOA BEACH CSWY STE 601
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3562
Practice Address - Country:US
Practice Address - Phone:321-868-5833
Practice Address - Fax:321-868-5854
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005369363LA2200X
FL11005369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109658200Medicaid
FLP9072OtherHF MA