Provider Demographics
NPI:1972915270
Name:KING, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9642
Mailing Address - Country:US
Mailing Address - Phone:707-535-9806
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE STE D
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:707-535-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160362934314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility