Provider Demographics
NPI:1295465953
Name:CARDER, MELISSA MERCEDES (PTA)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MERCEDES
Last Name:CARDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:MERCEDES
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 MOUNTAIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1533
Mailing Address - Country:US
Mailing Address - Phone:509-979-0838
Mailing Address - Fax:
Practice Address - Street 1:1520 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3738
Practice Address - Country:US
Practice Address - Phone:509-979-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160235990225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP160235990OtherWASHINGTON STATE DEPARTMENT OF HEALTH