Provider Demographics
NPI:1780118885
Name:WAYBRANT-ENNIS, MELISSA (APRN, DNP, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:WAYBRANT-ENNIS
Suffix:
Gender:F
Credentials:APRN, DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5964 US HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-8694
Mailing Address - Country:US
Mailing Address - Phone:302-981-8484
Mailing Address - Fax:833-672-3395
Practice Address - Street 1:5964 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-8694
Practice Address - Country:US
Practice Address - Phone:302-981-8484
Practice Address - Fax:833-672-3395
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015760363L00000X, 363LP0808X
FL11003223363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104165900Medicaid
FL11003223OtherAPRN
IL209015760OtherADVANCED PRACTICE NURSE