Provider Demographics
NPI:1588484562
Name:GONZAGA, MELISSA GISELLE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:GISELLE
Last Name:GONZAGA
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23709 101ST PL SE APT H102
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4250
Mailing Address - Country:US
Mailing Address - Phone:253-398-4460
Mailing Address - Fax:
Practice Address - Street 1:23709 101ST PL SE APT H102
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-4250
Practice Address - Country:US
Practice Address - Phone:253-398-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter