Healthcare Provider Details

I. General information

NPI: 1821753385
Provider Name (Legal Business Name): MELISSA M MCVICKER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4299 A1A S
ST AUGUSTINE FL
32080-7421
US

IV. Provider business mailing address

105 MARINER HEALTH WAY STE 213
SAINT AUGUSTINE FL
32086-3251
US

V. Phone/Fax

Practice location:
  • Phone: 904-679-3449
  • Fax:
Mailing address:
  • Phone: 904-217-4259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number047981
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT41821
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: