Provider Demographics
NPI:1093960080
Name:NICKELS, MELINDA (ND, LAC)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PIER 1 STE 308
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-6338
Mailing Address - Country:US
Mailing Address - Phone:503-974-0914
Mailing Address - Fax:888-972-3725
Practice Address - Street 1:10 PIER 1 STE 308
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6338
Practice Address - Country:US
Practice Address - Phone:503-974-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60054014171100000X
ORAC01291171100000X
WANT60051160175F00000X
OR1669175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist