Provider Demographics
NPI:1477340370
Name:PARKS, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PARKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13911 SHIREVA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2036
Mailing Address - Country:US
Mailing Address - Phone:503-858-5488
Mailing Address - Fax:
Practice Address - Street 1:1130 NW 22ND AVE STE 320
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2970
Practice Address - Country:US
Practice Address - Phone:503-295-2546
Practice Address - Fax:503-295-2546
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OR172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty