Provider Demographics
NPI:1336401876
Name:BURCHARDT, MELISSA MARIE (RD, CD, CGP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:BURCHARDT
Suffix:
Gender:F
Credentials:RD, CD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 BROOK RIDGE COURT NORTH
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-894-8522
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD
Practice Address - Street 2:SUITE 222
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:262-754-4910
Practice Address - Fax:262-754-4913
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI888249133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered