Healthcare Provider Details

I. General information

NPI: 1114612637
Provider Name (Legal Business Name): ANNAMARIA MELTON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

IV. Provider business mailing address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

V. Phone/Fax

Practice location:
  • Phone: 509-788-1702
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOL61432750
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOL.OL.61432750
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: