Healthcare Provider Details

I. General information

NPI: 1013435205
Provider Name (Legal Business Name): MELISSA ANN ELLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 MALABAR RD STE B
MALABAR FL
32950-3140
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-312-3463
  • Fax: 321-409-6811
Mailing address:
  • Phone: 321-312-3463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11026672
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP135067
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: