Provider Demographics
NPI:1699891028
Name:MILLER, MELODIE SHERLAINE (ARNP)
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:SHERLAINE
Last Name:MILLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 KINGSLEY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4463
Mailing Address - Country:US
Mailing Address - Phone:904-278-5644
Mailing Address - Fax:904-278-5575
Practice Address - Street 1:3292 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-4357
Practice Address - Country:US
Practice Address - Phone:904-291-5561
Practice Address - Fax:904-291-5575
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-070054363L00000X
FLARNP9294028363LF0000X
FLARNP 9294028363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051554172Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER