Healthcare Provider Details

I. General information

NPI: 1558339218
Provider Name (Legal Business Name): MELISSA MARYLYN DURHAM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3278 MITCHELL BLVD # 905
MOODY AFB GA
31699-1500
US

IV. Provider business mailing address

3278 MITCHELL BLVD # 905
MOODY AFB GA
31699-1500
US

V. Phone/Fax

Practice location:
  • Phone: 229-257-7393
  • Fax:
Mailing address:
  • Phone: 229-257-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number40QA01042400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA01042400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: