Provider Demographics
NPI:1861042707
Name:FREE-STOUDER, MELLISA JANE LEE (NP)
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:JANE LEE
Last Name:FREE-STOUDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1703
Mailing Address - Country:US
Mailing Address - Phone:541-805-1020
Mailing Address - Fax:
Practice Address - Street 1:STUDENT HEALTH CENTER
Practice Address - Street 2:ONE UNIVERSITY BLVD.
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-962-3524
Practice Address - Fax:541-962-3825
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201907957NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily