Provider Demographics
NPI:1639307473
Name:VANDERMISSEN, MELISSA A (DC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:VANDERMISSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3860 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-9306
Mailing Address - Country:US
Mailing Address - Phone:920-770-3250
Mailing Address - Fax:
Practice Address - Street 1:N3860 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-9306
Practice Address - Country:US
Practice Address - Phone:920-770-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4973-12111N00000X
MI2301009510111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639307473Medicaid
MIM24440017Medicare PIN
WIK400112343Medicare PIN