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General NPI Number Information
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NPI Number | 1235538802
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Entity Type | Individual
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Provider Name | MELISSA MARIE WALLINGA DCN, RD, LD
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Gender | Female
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 4272 E WESTPORT CT
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City | MERIDIAN
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State | ID
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Zip | 83642-7650
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Country | US
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Telephone | 712-540-3072
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Fax |
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Provider Business Mailing Address
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Address Line | 1603 CAPITOL AVE STE 411F
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City | CHEYENNE
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State | WY
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Zip | 82001-4569
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Country | US
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Telephone | 712-540-3072
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number | D-827
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License Number State | ID
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