Provider Demographics
NPI:1063653277
Name:MOELLER, MELANIE (LMP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19950 S PRAIRIE RD E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7901
Mailing Address - Country:US
Mailing Address - Phone:253-862-1555
Mailing Address - Fax:253-862-1557
Practice Address - Street 1:19950 S PRAIRIE RD E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7901
Practice Address - Country:US
Practice Address - Phone:253-862-1555
Practice Address - Fax:253-862-1557
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60077018174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist