Provider Demographics
NPI:1710998273
Name:BARRETT, MELODY A (LMP)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:A
Last Name:BARRETT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:A
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15073
Mailing Address - Street 2:
Mailing Address - City:FRITZ CREEK
Mailing Address - State:AK
Mailing Address - Zip Code:99603-6073
Mailing Address - Country:US
Mailing Address - Phone:425-327-0979
Mailing Address - Fax:
Practice Address - Street 1:808 E. END RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-226-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5968BAOtherREGENCE BLUE SHIELD