Provider Demographics
NPI:1881676641
Name:FEDERSPIEL, MELISSA LYNETT (FNP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LYNETT
Last Name:FEDERSPIEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:LYNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:5736 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3750
Mailing Address - Country:US
Mailing Address - Phone:971-258-1120
Mailing Address - Fax:
Practice Address - Street 1:5736 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3750
Practice Address - Country:US
Practice Address - Phone:971-258-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350112NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
J555 08OtherPACIFIC SOURCE
911019392OtherCOMMERCIAL