Healthcare Provider Details

I. General information

NPI: 1740560481
Provider Name (Legal Business Name): MELISSA FANNING TATE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19089 FLORIDA BLVD
ALBANY LA
70711-3603
US

IV. Provider business mailing address

PO BOX 1536
ALBANY LA
70711-1536
US

V. Phone/Fax

Practice location:
  • Phone: 225-209-7140
  • Fax:
Mailing address:
  • Phone: 985-320-0264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number06400
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number06400
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: