Healthcare Provider Details

I. General information

NPI: 1437977188
Provider Name (Legal Business Name): CARLA MEZA DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S WICKHAM RD
MELBOURNE FL
32904-1137
US

IV. Provider business mailing address

162 PEREGRINE DRIVE
INDIALANTIC FL
32903
US

V. Phone/Fax

Practice location:
  • Phone: 321-400-1220
  • Fax:
Mailing address:
  • Phone: 321-960-8654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11035572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: