Provider Demographics
NPI:1952802043
Name:KOBACK, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:KOBACK
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 1:1205 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7466
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:386-269-1847
Practice Address - Street 1:2160 HOWLAND BLVD STE 110
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-3468
Practice Address - Country:US
Practice Address - Phone:386-532-0515
Practice Address - Fax:386-532-0516
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002961363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103491600Medicaid