Provider Demographics
NPI:1780968396
Name:NIEWALD, MELISSA KATHLEEN (RN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KATHLEEN
Last Name:NIEWALD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3268 GWENGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3311
Mailing Address - Country:US
Mailing Address - Phone:314-392-7217
Mailing Address - Fax:
Practice Address - Street 1:3268 GWENGREEN DR.
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-392-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO163W00000X163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse