Basic Information
| Provider Information | |||||||||
| NPI: | 1770574865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOALEN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | JESSEMAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JESSEMAN | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP - PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | UFJAX - DEPT. OF NEPHROLOGY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831013 | ||||||||
| FaxNumber: | 9042442165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2005 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP1369112 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500009569 | 01 | FL | RAILROAD MEDICARE | OTHER | Y8425 | 01 | FL | BLUECROSS/BLUESHIELD | OTHER | 003124170B | 05 | GA | MEDICAID | 005547400 | 05 | FL | MEDICAID | 003214170A | 05 | GA | MEDICAID |