Provider Demographics
NPI:1114705076
Name:GOODE, MELISSA RENEE (MPH, RDN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:GOODE
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 W KAIBAB LN APT 24B
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-5112
Mailing Address - Country:US
Mailing Address - Phone:760-685-6008
Mailing Address - Fax:
Practice Address - Street 1:1080 W KAIBAB LN APT 24B
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5112
Practice Address - Country:US
Practice Address - Phone:760-685-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86378617133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty