Provider Demographics
NPI:1255807251
Name:MARTIN, MELISSA (TRICHOLOGIST)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:TRICHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 E INDEPENDENCE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7442
Mailing Address - Country:US
Mailing Address - Phone:980-636-7668
Mailing Address - Fax:
Practice Address - Street 1:4401 E INDEPENDENCE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7442
Practice Address - Country:US
Practice Address - Phone:980-636-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16599261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center