Provider Demographics
NPI:1619542693
Name:CAUDLE, MELISSA ANN (MHE, CWP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:CAUDLE
Suffix:
Gender:F
Credentials:MHE, CWP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7070 RUNNING IRON LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3817
Mailing Address - Country:US
Mailing Address - Phone:208-406-3131
Mailing Address - Fax:
Practice Address - Street 1:7070 RUNNING IRON LN
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3817
Practice Address - Country:US
Practice Address - Phone:208-406-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator