Provider Demographics
NPI:1053513341
Name:EVERSON, MELISSA ANN (RD)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:EVERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 NW NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-1925
Mailing Address - Country:US
Mailing Address - Phone:360-740-1454
Mailing Address - Fax:360-740-2708
Practice Address - Street 1:360 NW NORTH ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-1925
Practice Address - Country:US
Practice Address - Phone:360-740-1454
Practice Address - Fax:360-740-2708
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001266136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8282014Medicaid