1073478822 NPI number — MELISSA RENEA DORRIS CO70060132

Table of content: MELISSA RENEA DORRIS CO70060132 (NPI 1073478822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073478822 NPI number — MELISSA RENEA DORRIS CO70060132

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORRIS
Provider First Name:
MELISSA
Provider Middle Name:
RENEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CO70060132
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073478822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 S GLENN ST APT 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTESANO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98563-3924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-464-6872
Provider Business Mailing Address Fax Number:
360-464-6980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 SIMPSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOQUIAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98550-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-464-6872
Provider Business Practice Location Address Fax Number:
360-464-6980
Provider Enumeration Date:
12/23/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CO.70060132 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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