Healthcare Provider Details

I. General information

NPI: 1811274681
Provider Name (Legal Business Name): MELINDA C MUSSELMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 01/29/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 CRAGWOLD RD
SAINT LOUIS MO
63122-7013
US

IV. Provider business mailing address

11511 CRAGWOLD RD
SAINT LOUIS MO
63122-7013
US

V. Phone/Fax

Practice location:
  • Phone: 816-536-4236
  • Fax:
Mailing address:
  • Phone: 816-536-4236
  • Fax: 877-826-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2008000191
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: