Provider Demographics
NPI:1770856742
Name:MULLIGAN, MELISSA ANNE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANNE
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:3850 PARK NICOLLET BLVD
Mailing Address - Street 2:NUTRITION - FAMILY PRACTICE
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:NUTRITION - FAMILY PRACTICE
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3052133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered