Healthcare Provider Details

I. General information

NPI: 1427585751
Provider Name (Legal Business Name): MELANIE MASON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3074 W LAKE MARY BLVD STE 132
LAKE MARY FL
32746-6749
US

IV. Provider business mailing address

3715 N BUSINESS DR STE 202
FAYETTEVILLE AR
72703-5288
US

V. Phone/Fax

Practice location:
  • Phone: 407-917-0322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT3456
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9305106
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: