Provider Demographics
NPI:1740639426
Name:PEARSON, MELISSA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PEARSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:13718 SIGLER ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2324
Mailing Address - Country:US
Mailing Address - Phone:608-445-5874
Mailing Address - Fax:
Practice Address - Street 1:12500 S APOPKA VINELAND RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32836-6723
Practice Address - Country:US
Practice Address - Phone:407-934-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL41172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer