Basic Information
Provider Information | |||||||||
NPI: | 1760913057 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRADLEY | ||||||||
FirstName: | MELANIE | ||||||||
MiddleName: | LORETTA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BURNETT | ||||||||
OtherFirstName: | MELANIE | ||||||||
OtherMiddleName: | LORETTA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 40 ROYAL LAKE DR | ||||||||
Address2: |   | ||||||||
City: | PONTE VEDRA | ||||||||
State: | FL | ||||||||
PostalCode: | 320810537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042088724 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 MARKETSIDE AVE STE 405 | ||||||||
Address2: |   | ||||||||
City: | PONTE VEDRA | ||||||||
State: | FL | ||||||||
PostalCode: | 320811542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042239100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2017 | ||||||||
LastUpdateDate: | 08/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS16693 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.