Provider Demographics
NPI:1932795960
Name:MIROTA, MELISSA J (LD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:MIROTA
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:J
Other - Last Name:FENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LD
Mailing Address - Street 1:906 N POLK ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-1731
Mailing Address - Country:US
Mailing Address - Phone:908-797-5815
Mailing Address - Fax:
Practice Address - Street 1:906 N POLK ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1731
Practice Address - Country:US
Practice Address - Phone:908-797-5815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1888133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered