Basic Information
| Provider Information | |||||||||
| NPI: | 1215051834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603362178 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603362178 | ||||||||
| FaxNumber: | 3603362642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 01/02/2014 | ||||||||
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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 | 231H00000X | LD00000971 | WA | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | LD00000971 | WA | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 99220 | 01 | WA | HEARPO | OTHER | 108285 | 01 | WA | L&I NUMBER | OTHER |