Provider Demographics
NPI:1225436413
Name:WILLEMS, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILLEMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 E 76TH AVE
Mailing Address - Street 2:1
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-2849
Mailing Address - Country:US
Mailing Address - Phone:907-202-3379
Mailing Address - Fax:907-644-0790
Practice Address - Street 1:709 E 76TH AVE
Practice Address - Street 2:1
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-2849
Practice Address - Country:US
Practice Address - Phone:907-202-3379
Practice Address - Fax:907-644-0790
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1629601171M00000X
AK1624023171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1629601Medicaid
AK1624023Medicaid