Healthcare Provider Details

I. General information

NPI: 1366991374
Provider Name (Legal Business Name): MELISSA KELLY MILICEVIC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA KELLY VAN HORN NP

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 05/23/2020
Certification Date: 05/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 JANET ST STE B
VALDOSTA GA
31602-2643
US

IV. Provider business mailing address

5715 GARDENIA CIR
LAKE PARK GA
31636-3168
US

V. Phone/Fax

Practice location:
  • Phone: 229-375-0747
  • Fax: 229-389-2274
Mailing address:
  • Phone: 229-886-9431
  • Fax: 229-389-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN217925
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN217925
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: