Healthcare Provider Details

I. General information

NPI: 1639534415
Provider Name (Legal Business Name): MARISSA MEKELBURG MS, RDN, CLT, HHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 52ND AVE
GREELEY CO
80634-8766
US

IV. Provider business mailing address

3119 52ND AVE
GREELEY CO
80634-8766
US

V. Phone/Fax

Practice location:
  • Phone: 970-518-2315
  • Fax:
Mailing address:
  • Phone: 970-518-2315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: