=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538478953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN MARIE MELITO D.P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2010
-----------------------------------------------------
Last Update Date | 06/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 N RICHARD JACKSON BLVD STE 130
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-2521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-235-6360
-----------------------------------------------------
Fax | 850-235-8871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2699 SHMG/HPE
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32513-2699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-235-6360
-----------------------------------------------------
Fax | 850-235-8871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT27421
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 23338
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------