Provider Demographics
NPI:1124463112
Name:WEATHERSPOON, MELANIE DAVIS
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:DAVIS
Last Name:WEATHERSPOON
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 1:1714 52ND TER SW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-5652
Mailing Address - Country:US
Mailing Address - Phone:239-352-6629
Mailing Address - Fax:239-455-7757
Practice Address - Street 1:1714 52ND TER SW
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-5652
Practice Address - Country:US
Practice Address - Phone:239-352-6629
Practice Address - Fax:239-455-7757
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL004211600311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004211600Medicaid