Provider Demographics
NPI:1396719902
Name:EDWARDS, MELISSA SEELEY (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SEELEY
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:SEELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1905 CORPORATE SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1940
Mailing Address - Country:US
Mailing Address - Phone:904-720-0799
Mailing Address - Fax:904-720-5225
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1700
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8344
Practice Address - Country:US
Practice Address - Phone:904-398-0125
Practice Address - Fax:904-398-1832
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9100652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS36637Medicare UPIN