Provider Demographics
NPI:1932625209
Name:LAVECCHIA, MELINDA MATHERLY (PA)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:MATHERLY
Last Name:LAVECCHIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:114 CANAL ST STE 503
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4261
Mailing Address - Country:US
Mailing Address - Phone:912-450-6300
Mailing Address - Fax:912-450-6303
Practice Address - Street 1:114 CANAL ST STE 503
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-450-6300
Practice Address - Fax:912-450-6303
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA008534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant