Provider Demographics
NPI:1760197990
Name:PHELAN, MELISSA ANNE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:PHELAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12018 NE 109TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3421
Mailing Address - Country:US
Mailing Address - Phone:360-721-5571
Mailing Address - Fax:
Practice Address - Street 1:12018 NE 109TH ST UNIT A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3421
Practice Address - Country:US
Practice Address - Phone:360-721-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN605929782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty