Provider Demographics
NPI:1720575525
Name:RICHARDSON, MELANIE LYNN (DOM)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 MESQUITE WOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4054
Mailing Address - Country:US
Mailing Address - Phone:505-250-4051
Mailing Address - Fax:
Practice Address - Street 1:7528 4TH ST NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6683
Practice Address - Country:US
Practice Address - Phone:505-250-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM743171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist