Healthcare Provider Details

I. General information

NPI: 1649078338
Provider Name (Legal Business Name): MELODY GROSS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13925 INTERURBAN AVE S STE 120
TUKWILA WA
98168-5718
US

IV. Provider business mailing address

13925 INTERURBAN AVE S STE 120
TUKWILA WA
98168-5718
US

V. Phone/Fax

Practice location:
  • Phone: 206-948-0096
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: