Healthcare Provider Details

I. General information

NPI: 1871214452
Provider Name (Legal Business Name): KRISTEN MELERVEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN SHEPPARD

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3191 HARBOR BLVD STE A&B
PORT CHARLOTTE FL
33952-6755
US

IV. Provider business mailing address

7454 ROCKWELL AVE
NORTH PORT FL
34291-5734
US

V. Phone/Fax

Practice location:
  • Phone: 941-883-4518
  • Fax:
Mailing address:
  • Phone: 609-510-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11021705
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: