Provider Demographics
NPI:1013203926
Name:LUSTIC-LONG, MELISSA K (RDN, ATC, CSCS)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:K
Last Name:LUSTIC-LONG
Suffix:
Gender:F
Credentials:RDN, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E 38TH ST
Mailing Address - Street 2:MAC 202
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16546-0002
Mailing Address - Country:US
Mailing Address - Phone:814-824-2084
Mailing Address - Fax:
Practice Address - Street 1:501 E 38TH ST
Practice Address - Street 2:MAC 202
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16546-0002
Practice Address - Country:US
Practice Address - Phone:814-824-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0004232255A2300X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer