Healthcare Provider Details

I. General information

NPI: 1700617065
Provider Name (Legal Business Name): MELANIE KOLMETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 SCENIC HILL CIRCLE
BONIFAY FL
32425-3060
US

IV. Provider business mailing address

3010 DAWKINS ST
VERNON FL
32462-2200
US

V. Phone/Fax

Practice location:
  • Phone: 850-547-8500
  • Fax:
Mailing address:
  • Phone: 850-849-3019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11034257
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: