Provider Demographics
NPI:1487793790
Name:TETREAULT, MELISSA JO
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JO
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11009 69TH ST NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-2047
Mailing Address - Country:US
Mailing Address - Phone:425-334-6258
Mailing Address - Fax:425-334-1187
Practice Address - Street 1:303 91ST AVE NE
Practice Address - Street 2:SUITE E504
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98205-1541
Practice Address - Country:US
Practice Address - Phone:425-334-6258
Practice Address - Fax:425-334-1187
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017810174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist