Provider Demographics
NPI:1760045793
Name:ACOSTA, MELODY WILSON (MPH RD)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:WILSON
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MPH RD
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:SUE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 13TH ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1204
Mailing Address - Country:US
Mailing Address - Phone:541-380-9059
Mailing Address - Fax:
Practice Address - Street 1:811 13TH ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1204
Practice Address - Country:US
Practice Address - Phone:541-380-9059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D000480133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric