Provider Demographics
NPI:1447462189
Name:CLARK, MELISSA KIPP (AUD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:KIPP
Last Name:CLARK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 MANATEE AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3743
Mailing Address - Country:US
Mailing Address - Phone:941-747-7620
Mailing Address - Fax:941-747-7148
Practice Address - Street 1:5304 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3743
Practice Address - Country:US
Practice Address - Phone:941-747-7620
Practice Address - Fax:941-747-7148
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY898231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3967300Medicaid
FL3967300Medicaid