Provider Demographics
NPI:1457609042
Name:POWELL, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 HAILEY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9535
Mailing Address - Country:US
Mailing Address - Phone:517-648-4434
Mailing Address - Fax:
Practice Address - Street 1:2900 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2379
Practice Address - Country:US
Practice Address - Phone:269-408-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered