Provider Demographics
NPI:1326557141
Name:KINGSTON, MELISSA L (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:KINGSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 W GORE ST STE 403
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1049
Mailing Address - Country:US
Mailing Address - Phone:321-841-3050
Mailing Address - Fax:321-843-3570
Practice Address - Street 1:100 W GORE ST STE 403
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1049
Practice Address - Country:US
Practice Address - Phone:321-841-3050
Practice Address - Fax:321-843-3570
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ363A00000X
FLPA9119140363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124034000Medicaid