Provider Demographics
NPI:1255442802
Name:PACHECO, MELODYE LEE
Entity type:Individual
Prefix:
First Name:MELODYE
Middle Name:LEE
Last Name:PACHECO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELODYE
Other - Middle Name:LEE
Other - Last Name:SHANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1221 NE 267TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-8905
Mailing Address - Country:US
Mailing Address - Phone:360-834-3171
Mailing Address - Fax:
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6055
Practice Address - Country:US
Practice Address - Phone:360-896-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001784156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician