Healthcare Provider Details

I. General information

NPI: 1306552989
Provider Name (Legal Business Name): MELISSA SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E VISTA LAKE AVE
POLK CITY IA
50226-3401
US

IV. Provider business mailing address

406 E VISTA LAKE AVE
POLK CITY IA
50226-3401
US

V. Phone/Fax

Practice location:
  • Phone: 515-779-3462
  • Fax:
Mailing address:
  • Phone: 515-779-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number118713
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: