Healthcare Provider Details

I. General information

NPI: 1205392354
Provider Name (Legal Business Name): MELISSA ANNE HUNZIKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA ANNE GREEN

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 W MAIN ST
GOLDENDALE WA
98620-9597
US

IV. Provider business mailing address

228 W MAIN ST
GOLDENDALE WA
98620-9597
US

V. Phone/Fax

Practice location:
  • Phone: 509-773-4565
  • Fax:
Mailing address:
  • Phone: 509-773-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60692307
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: