Provider Demographics
NPI:1770718678
Name:BOYLE, MELISSA JANE (APRN)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JANE
Last Name:BOYLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JANE
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3948 3RD ST S STE 151
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5847
Mailing Address - Country:US
Mailing Address - Phone:619-641-9776
Mailing Address - Fax:
Practice Address - Street 1:12058 SAN JOSE BLVD STE 1003
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8667
Practice Address - Country:US
Practice Address - Phone:904-391-9875
Practice Address - Fax:904-321-9890
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9320462163W00000X
FLMA35203225700000X
FL11007220363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9320462Medicaid