Provider Demographics
NPI:1104420744
Name:MUELLER-SOUPHANAVONG, MELISSA (LMT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MUELLER-SOUPHANAVONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7449 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-2708
Mailing Address - Country:US
Mailing Address - Phone:907-244-2146
Mailing Address - Fax:
Practice Address - Street 1:7449 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-2708
Practice Address - Country:US
Practice Address - Phone:907-244-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK152646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist