Provider Demographics
NPI:1831265198
Name:KOON, MELISSA A (RD, LD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:KOON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 WOOLWORTH AVENUE
Mailing Address - Street 2:NUTRITION (120)
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-3309
Mailing Address - Country:US
Mailing Address - Phone:402-886-8830
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVENUE
Practice Address - Street 2:NUTRITION 120
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-3309
Practice Address - Country:US
Practice Address - Phone:402-886-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002538133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered