Healthcare Provider Details

I. General information

NPI: 1366991812
Provider Name (Legal Business Name): MELISSA RENAE CLEGG ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY SUITE 301
DAYTONA BEACH FL
32117-5168
US

IV. Provider business mailing address

305 MEMORIAL MEDICAL PKWY SUITE 301
DAYTONA BEACH FL
32117-5168
US

V. Phone/Fax

Practice location:
  • Phone: 386-671-0691
  • Fax: 386-671-0694
Mailing address:
  • Phone: 386-671-0691
  • Fax: 386-671-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9190430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: