Provider Demographics
NPI:1689234742
Name:NIEHUS, MELANIE RAE (OD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:RAE
Last Name:NIEHUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S BOUNDARY ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-3105
Mailing Address - Country:US
Mailing Address - Phone:719-641-5432
Mailing Address - Fax:
Practice Address - Street 1:4200 N FREEWAY RD # 120
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2153
Practice Address - Country:US
Practice Address - Phone:719-207-8628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003492152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist