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 STE 3
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7464
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:
Practice Address - Street 1:1200 DELTONA BLVD
Practice Address - Street 2:SUITE 40A
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-6386
Practice Address - Country:US
Practice Address - Phone:386-202-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2024-07-22
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