Provider Demographics
NPI:1588197404
Name:MARTIN, MELITTA (LMT)
Entity Type:Individual
Prefix:
First Name:MELITTA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 OLD STEESE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-451-7246
Mailing Address - Fax:
Practice Address - Street 1:1755 RICHARDSON HWY
Practice Address - Street 2:
Practice Address - City:DELTA JUNCTION
Practice Address - State:AK
Practice Address - Zip Code:99737
Practice Address - Country:US
Practice Address - Phone:907-895-5055
Practice Address - Fax:907-895-5057
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK109608225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist