Provider Demographics
NPI:1932262284
Name:LARSON, MELANIE FONTAINE (MA, RD)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:FONTAINE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 ALPINE CT
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-8589
Mailing Address - Country:US
Mailing Address - Phone:707-782-9667
Mailing Address - Fax:
Practice Address - Street 1:5900 STATE FARM DR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2149
Practice Address - Country:US
Practice Address - Phone:707-206-3212
Practice Address - Fax:707-206-3041
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered