Provider Demographics
NPI:1720502750
Name:FRIETCHEN, MELLISSA RAE (CERTIFIED ORTHOTIST)
Entity type:Individual
Prefix:
First Name:MELLISSA
Middle Name:RAE
Last Name:FRIETCHEN
Suffix:
Gender:F
Credentials:CERTIFIED ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 E WALNUT LAWN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4202
Mailing Address - Country:US
Mailing Address - Phone:417-755-7430
Mailing Address - Fax:417-755-7431
Practice Address - Street 1:1246 E WALNUT LAWN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4202
Practice Address - Country:US
Practice Address - Phone:417-755-7430
Practice Address - Fax:417-755-7431
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO622556702Medicaid