Provider Demographics
NPI:1538321666
Name:MAXIM, MELISSA DALE
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:DALE
Last Name:MAXIM
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:DALE
Other - Last Name:MAXIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD
Mailing Address - Street 1:54 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-2282
Mailing Address - Country:US
Mailing Address - Phone:804-350-1142
Mailing Address - Fax:
Practice Address - Street 1:320 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1900
Practice Address - Country:US
Practice Address - Phone:276-666-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered