Provider Demographics
NPI:1366991374
Name:MILICEVIC, MELISSA KELLY (NP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:KELLY
Last Name:MILICEVIC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:KELLY
Other - Last Name:VAN HORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:5715 GARDENIA CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-3168
Mailing Address - Country:US
Mailing Address - Phone:229-886-9431
Mailing Address - Fax:229-389-2274
Practice Address - Street 1:304 JANET ST STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2643
Practice Address - Country:US
Practice Address - Phone:229-375-0747
Practice Address - Fax:229-389-2274
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217925363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care