Provider Demographics
NPI:1811309818
Name:ILLINGWORTH, MELISSA MARIE
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MARIE
Last Name:ILLINGWORTH
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 1:15178 JACK PINE WAY
Mailing Address - Street 2:
Mailing Address - City:MAGALIA
Mailing Address - State:CA
Mailing Address - Zip Code:95954-9116
Mailing Address - Country:US
Mailing Address - Phone:760-828-8027
Mailing Address - Fax:
Practice Address - Street 1:757 FIR ST
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-4532
Practice Address - Country:US
Practice Address - Phone:760-828-8027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-24
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24432225700000X
CA17372171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist