Provider Demographics
NPI:1417428343
Name:WYRWITZKE, MELANIE ANN
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:WYRWITZKE
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 1:2120 EXCHANGE ST STE 209
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3364
Mailing Address - Country:US
Mailing Address - Phone:503-338-2993
Mailing Address - Fax:503-338-2996
Practice Address - Street 1:2120 EXCHANGE ST STE 209
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3364
Practice Address - Country:US
Practice Address - Phone:503-338-2993
Practice Address - Fax:503-338-2996
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator