Provider Demographics
NPI:1235538802
Name:WALLINGA, MELISSA MARIE (DCN, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:WALLINGA
Suffix:
Gender:F
Credentials:DCN, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 CAPITOL AVE STE 411F
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4569
Mailing Address - Country:US
Mailing Address - Phone:712-540-3072
Mailing Address - Fax:
Practice Address - Street 1:4272 E WESTPORT CT
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7650
Practice Address - Country:US
Practice Address - Phone:712-540-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-827133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric