Provider Demographics
NPI:1174974307
Name:DERHAK, MELISSA (LPN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DERHAK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2502
Mailing Address - Country:US
Mailing Address - Phone:541-344-3574
Mailing Address - Fax:541-344-5652
Practice Address - Street 1:715 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2502
Practice Address - Country:US
Practice Address - Phone:541-344-3574
Practice Address - Fax:541-344-5652
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201330198164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230475Medicaid