Provider Demographics
NPI:1972070647
Name:WILCOXON, MELISSA ANN (RDN, LN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WILCOXON
Suffix:
Gender:F
Credentials:RDN, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 S BAHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-3441
Mailing Address - Country:US
Mailing Address - Phone:507-227-2913
Mailing Address - Fax:
Practice Address - Street 1:1305 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0401
Practice Address - Country:US
Practice Address - Phone:605-328-1518
Practice Address - Fax:605-328-1516
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered