Basic Information
| Provider Information | |||||||||
| NPI: | 1235569542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOETH | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ADA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HULL | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | ADA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 520 PALM COAST PKWY SW | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321374743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665406 | ||||||||
| FaxNumber: | 8589665859 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 PALM COAST PKWY SW | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321374743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864464101 | ||||||||
| FaxNumber: | 3864472161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2013 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 26180 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.