Provider Demographics
NPI:1922647890
Name:MELARA, KATELYN MARIE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:MELARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15815 NE 48TH CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5215
Mailing Address - Country:US
Mailing Address - Phone:360-936-1592
Mailing Address - Fax:
Practice Address - Street 1:15815 NE 48TH CIR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-5215
Practice Address - Country:US
Practice Address - Phone:360-936-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WANUTR.NU.61088083133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health