Healthcare Provider Details

I. General information

NPI: 1225218233
Provider Name (Legal Business Name): MELISSA RAYBURN ROTELLA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA RAYBURN POORE NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE MEDICAL OFFICE TOWER 9TH FLOOR
ATLANTA GA
30308-2247
US

IV. Provider business mailing address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-7243
  • Fax:
Mailing address:
  • Phone: 404-712-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN154553NP
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberRN154553NP
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN154553NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: