Provider Demographics
NPI:1134524341
Name:MITCHELL, MELISSA OMEGA (RD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:OMEGA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7073 MACKEY LN
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29449-6289
Mailing Address - Country:US
Mailing Address - Phone:843-323-7162
Mailing Address - Fax:
Practice Address - Street 1:5319 PARKSHIRE WAY
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-2051
Practice Address - Country:US
Practice Address - Phone:843-767-2121
Practice Address - Fax:843-767-2102
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1041133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered