Provider Demographics
NPI:1215702923
Name:STOCKWELL, MELISSA (RDN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 NW 39TH AVE STE 130-56
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-7331
Mailing Address - Country:US
Mailing Address - Phone:352-757-7724
Mailing Address - Fax:
Practice Address - Street 1:4120 NW 37TH PL APT 204
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7040
Practice Address - Country:US
Practice Address - Phone:352-757-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered