Healthcare Provider Details

I. General information

NPI: 1952802043
Provider Name (Legal Business Name): MELODY KOBACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 DELTONA BLVD SUITE 40A
DELTONA FL
32725-6386
US

IV. Provider business mailing address

1205 S WOODLAND BLVD STE 3
DELAND FL
32720-7464
US

V. Phone/Fax

Practice location:
  • Phone: 386-202-6025
  • Fax:
Mailing address:
  • Phone: 386-202-6025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11002961
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11002961
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11002961
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11002961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: