Provider Demographics
NPI:1063980266
Name:CARLSON, MELANIE WESNER
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:WESNER
Last Name:CARLSON
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 1:3422 AUGUSTINE ELM CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1979
Mailing Address - Country:US
Mailing Address - Phone:904-885-7323
Mailing Address - Fax:
Practice Address - Street 1:3422 AUGUSTINE ELM CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1979
Practice Address - Country:US
Practice Address - Phone:904-885-7323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist