Healthcare Provider Details

I. General information

NPI: 1184097537
Provider Name (Legal Business Name): MELISSA MARIE WILLIFORD R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12055 W 2ND PL
LAKEWOOD CO
80228-1506
US

IV. Provider business mailing address

4851 INDEPENDENCE ST SUITE 200
WHEAT RIDGE CO
80033-6715
US

V. Phone/Fax

Practice location:
  • Phone: 303-425-0300
  • Fax:
Mailing address:
  • Phone: 303-425-0300
  • Fax: 303-432-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number86013110
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number86013110
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86013110
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: