Provider Demographics
NPI:1528284668
Name:MOUTON, MELISSA (MS, RD, CD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MOUTON
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9611 NE 140TH CT
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-5182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8266 LAKE CITY WAY NE, STE 3C
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115
Practice Address - Country:US
Practice Address - Phone:425-205-9236
Practice Address - Fax:866-313-2486
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001933133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered