Provider Demographics
NPI:1376084848
Name:BERNT, MELISSA ROSE (LMP)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ROSE
Last Name:BERNT
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:PO BOX 302
Mailing Address - Street 2:33 EAST CASCADE DRIVE
Mailing Address - City:NORTH BONNEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98639-0302
Mailing Address - Country:US
Mailing Address - Phone:360-521-1523
Mailing Address - Fax:
Practice Address - Street 1:77 SW RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648-9198
Practice Address - Country:US
Practice Address - Phone:360-521-1523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020546171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00020546OtherCREDENTIALS FOR STATE OF WASHINGTON