Provider Demographics
NPI:1831415850
Name:KLESCHEN, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KLESCHEN
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-1850
Mailing Address - Fax:
Practice Address - Street 1:3075 N RESERVE ST
Practice Address - Street 2:SUITE Q
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1389
Practice Address - Country:US
Practice Address - Phone:406-327-1850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MT43243208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program