Basic Information
| Provider Information | |||||||||
| NPI: | 1124052006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603971500 | ||||||||
| FaxNumber: | 3603973128 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 NE 139TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986862719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973870 | ||||||||
| FaxNumber: | 3603973858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | AP30007582 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 9651506 | 05 | WA | MEDICAID | 269690 | 05 | OR | MEDICAID |