Provider Demographics
NPI:1306491857
Name:GEBHARDT, MELISSA NICOLE (APRN)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:NICOLE
Last Name:GEBHARDT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 VISTA LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0080
Mailing Address - Country:US
Mailing Address - Phone:573-239-0754
Mailing Address - Fax:
Practice Address - Street 1:3055 COUNTY ROAD 210 W STE 105
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7001
Practice Address - Country:US
Practice Address - Phone:904-223-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003025208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics