Provider Demographics
NPI:1598095101
Name:KETRENOS, MELISSA ANNE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANNE
Last Name:KETRENOS
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 1:9045 SW BARBUR BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4021
Mailing Address - Country:US
Mailing Address - Phone:503-679-9719
Mailing Address - Fax:
Practice Address - Street 1:9045 SW BARBUR BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4021
Practice Address - Country:US
Practice Address - Phone:503-679-9719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15460173C00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No173C00000XOther Service ProvidersReflexologist