Provider Demographics
NPI:1558790345
Name:MISENHEIMER, MELANIE (LAC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MISENHEIMER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10909 SW BOONES FERRY RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7725
Mailing Address - Country:US
Mailing Address - Phone:704-995-9926
Mailing Address - Fax:
Practice Address - Street 1:1804 NE MLK JR BLVD STE A-B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3980
Practice Address - Country:US
Practice Address - Phone:971-302-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC164953171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist