Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1023678281 |
---|---|
Provider Name | Melanie Domenech |
First Address | Fort Walton Beach, FL 32548-5271 |
Second Address | Fort Walton Beach, FL 32548-5271 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2019 |
Last Update Date | 19/06/2019 |