MEDICARE: DR. MELISSA MARYLYN DURHAM DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171000000X	Military Health Care Provider	40QA01042400	NJ
2	2251X0800X	Orthopedic Physical Therapist	40QA01042400	NJ

General Provider Information

NPI Number	:	1558339218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELISSA MARYLYN DURHAM DPT

Provider Business Mailing Address
First Line	:	3278 MITCHELL BLVD # 905
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-7393
Fax Number	:

Provider Business Practice Location Address
First Line	:	3278 MITCHELL BLVD # 905
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-7393
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	05/11/2022

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