Provider Demographics
NPI:1568748663
Name:BOLLMAN, MELISSA LYNN (RD)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LYNN
Last Name:BOLLMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5071 W SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4253
Mailing Address - Country:US
Mailing Address - Phone:917-680-2820
Mailing Address - Fax:
Practice Address - Street 1:5071 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4253
Practice Address - Country:US
Practice Address - Phone:917-680-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10144515133V00000X
NY00804506133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered