MEDICARE: MELISSA MAE-LYN NEIMOYER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	357950-3102	UT

General Provider Information

NPI Number	:	1093205338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MAE-LYN NEIMOYER RN

Provider Business Mailing Address
First Line	:	4460 S. HIGHLAND DRIVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3503
Country	:	US
Telephone Number	:	801-688-8862
Fax Number	:

Provider Business Practice Location Address
First Line	:	4460 S HIGHLAND DRIVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3503
Country	:	US
Telephone Number	:	801-688-8862
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2018
Last Update Date	:	05/11/2018

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