Provider Demographics
NPI:1902954720
Name:LACERNA-KIMBRELL, MELINDA L (MD)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:L
Last Name:LACERNA-KIMBRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 N. 18TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205
Mailing Address - Country:US
Mailing Address - Phone:805-607-8342
Mailing Address - Fax:
Practice Address - Street 1:5301 4TH AVENUE CIR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5623
Practice Address - Country:US
Practice Address - Phone:941-954-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109505208200000X
CAA724042086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A724040Medicaid
CA00A724040Medicaid