Provider Demographics
NPI:1457432288
Name:MELCHIORE, JOHANNA KATHRYN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:KATHRYN
Last Name:MELCHIORE
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:BOX 449
Mailing Address - Street 2:
Mailing Address - City:LA RONGE
Mailing Address - State:SASKATCHEWAN
Mailing Address - Zip Code:SOJ 1LO
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-768-4000
Practice Address - Fax:207-768-4373
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT0595Medicare ID - Type Unspecified