Provider Demographics
NPI:1871652255
Name:KIRK, MELISSA NICOLE (RD, CD, CDE)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICOLE
Last Name:KIRK
Suffix:
Gender:F
Credentials:RD, CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9432
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:1044 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2506
Practice Address - Country:US
Practice Address - Phone:360-353-9432
Practice Address - Fax:360-353-9440
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000860133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8432411Medicaid
WA8432411Medicaid