Healthcare Provider Details

I. General information

NPI: 1568748663
Provider Name (Legal Business Name): MELISSA LYNN BOLLMAN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5071 W SUNSET DR
LAKE OSWEGO OR
97035-4253
US

IV. Provider business mailing address

5071 W SUNSET DR
LAKE OSWEGO OR
97035-4253
US

V. Phone/Fax

Practice location:
  • Phone: 917-680-2820
  • Fax:
Mailing address:
  • Phone: 917-680-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10144515
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00804506
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: