Provider Demographics
NPI:1588890628
Name:ANDERSON, MELISSA ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-3211
Mailing Address - Country:US
Mailing Address - Phone:386-960-6362
Mailing Address - Fax:
Practice Address - Street 1:1200 LEXINGTON GREEN LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1013
Practice Address - Country:US
Practice Address - Phone:407-688-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20431225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant