Provider Demographics
NPI:1417001132
Name:BAKER, MELISSA NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICOLE
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:NICOLE
Other - Last Name:BAKER-COKLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3320 SE 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2854
Mailing Address - Country:US
Mailing Address - Phone:503-757-0837
Mailing Address - Fax:
Practice Address - Street 1:3320 SE 14TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-757-0837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6975174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist