MEDICARE: JACQUELYN MERRILL ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	ARNP9282570	FL

General Provider Information

NPI Number	:	1760996086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN MERRILL ARNP

Provider Business Mailing Address
First Line	:	PO BOX 361095
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32936-1095
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 BABCOCK ST NE STE 103
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-4639
Country	:	US
Telephone Number	:	321-312-4796
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2017
Last Update Date	:	11/22/2017

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