Provider Demographics
NPI:1083461180
Name:HENRICKSON, MELANIE JOY
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:JOY
Last Name:HENRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:JOY
Other - Last Name:MERTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3805 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4001
Mailing Address - Country:US
Mailing Address - Phone:218-340-7248
Mailing Address - Fax:
Practice Address - Street 1:3805 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4001
Practice Address - Country:US
Practice Address - Phone:218-340-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1039721133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered