Provider Demographics
NPI:1538543137
Name:ANDERSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEANNE
Other - Last Name:PERDUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2225 EXPOSITION DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5508
Mailing Address - Country:US
Mailing Address - Phone:805-547-7025
Mailing Address - Fax:
Practice Address - Street 1:285 SOUTH ST STE J
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5037
Practice Address - Country:US
Practice Address - Phone:805-547-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24871174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator