Provider Demographics
NPI:1902407695
Name:SUTHERLAND, MELANIE (LMT)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S RUE DE LA PAIX LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-0976
Mailing Address - Country:US
Mailing Address - Phone:907-315-0004
Mailing Address - Fax:
Practice Address - Street 1:1212 W MYSTERY AVE STE B
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6335
Practice Address - Country:US
Practice Address - Phone:907-521-8002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK156526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist