Healthcare Provider Details

I. General information

NPI: 1932894656
Provider Name (Legal Business Name): MELLITI MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9708 GILESPIE ST STE 109
LAS VEGAS NV
89183-7614
US

IV. Provider business mailing address

9708 GILESPIE ST STE 109
LAS VEGAS NV
89183-7614
US

V. Phone/Fax

Practice location:
  • Phone: 813-389-1267
  • Fax: 702-405-0625
Mailing address:
  • Phone: 813-389-1267
  • Fax: 702-405-0625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENESSIA MARIE MELLITI
Title or Position: CEO/FOUNDER
Credential: FNP-BC
Phone: 813-389-1267