Provider Demographics
NPI:1306552989
Name:SONG, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 E VISTA LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226-3401
Mailing Address - Country:US
Mailing Address - Phone:515-779-3462
Mailing Address - Fax:
Practice Address - Street 1:406 E VISTA LAKE AVE
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226-3401
Practice Address - Country:US
Practice Address - Phone:515-779-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA118713163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator