Provider Demographics
NPI:1982229316
Name:FUNK, MELISSA CHRISTINE (HIS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CHRISTINE
Last Name:FUNK
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 MCCULLOCH BLVD N STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6559
Mailing Address - Country:US
Mailing Address - Phone:928-854-5368
Mailing Address - Fax:
Practice Address - Street 1:1760 MCCULLOCH BLVD N STE 100
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6559
Practice Address - Country:US
Practice Address - Phone:928-854-5368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTHAD11562237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist