Provider Demographics
NPI:1366863896
Name:MINOTT, MELODY WANDA (LPN)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:WANDA
Last Name:MINOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16317 25TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-4510
Mailing Address - Country:US
Mailing Address - Phone:253-298-2796
Mailing Address - Fax:
Practice Address - Street 1:16317 25TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-4510
Practice Address - Country:US
Practice Address - Phone:253-298-2796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00046678164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse