1891381117 NPI number — MRS. MELISSA MARIE BALLARD-MARTIN A.P.R.N.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891381117 NPI number — MRS. MELISSA MARIE BALLARD-MARTIN A.P.R.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLARD-MARTIN
Provider First Name:
MELISSA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
A.P.R.N.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891381117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 SHIRCLIFF WAY
Provider Second Line Business Mailing Address:
SUITE 700 DEPAUL BLDG.
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-389-5333
Provider Business Mailing Address Fax Number:
904-389-5332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1563 KINGSLEY AVENUE
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-272-6161
Provider Business Practice Location Address Fax Number:
904-389-5332
Provider Enumeration Date:
12/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3-000140 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN11019017 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114473500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com