Healthcare Provider Details

I. General information

NPI: 1073300257
Provider Name (Legal Business Name): MELONY RICHARDSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6105 US HIGHWAY 98 N
LAKELAND FL
33809-6223
US

IV. Provider business mailing address

4731 DUNNIE DR
TAMPA FL
33614-1499
US

V. Phone/Fax

Practice location:
  • Phone: 863-858-4441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS36720
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11036872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: