Provider Demographics
NPI:1508670175
Name:HENDERSON, MELISSA CISNEROS (MS AND RDN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CISNEROS
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS AND RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S MARVIN AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-1940
Mailing Address - Country:US
Mailing Address - Phone:703-855-9371
Mailing Address - Fax:
Practice Address - Street 1:2222 S MARVIN AVE APT 205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-1940
Practice Address - Country:US
Practice Address - Phone:703-855-9371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86446977133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered