Provider Demographics
NPI:1932459963
Name:WUSTNER, MELISSA L (LMT, CNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:WUSTNER
Suffix:
Gender:F
Credentials:LMT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 N. HUNTERS WAY
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6170
Mailing Address - Country:US
Mailing Address - Phone:406-539-4852
Mailing Address - Fax:
Practice Address - Street 1:1547 HUNTERS WAY
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6170
Practice Address - Country:US
Practice Address - Phone:406-539-4852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT307225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist