Provider Demographics
NPI:1548736960
Name:MOSS, MELANIE JANE
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:JANE
Last Name:MOSS
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-6700
Mailing Address - Fax:208-625-6701
Practice Address - Street 1:1296 E POLSTON AVE STE C
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5217
Practice Address - Country:US
Practice Address - Phone:208-625-6700
Practice Address - Fax:208-625-6701
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1827363A00000X
IDPA1827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCS56802OtherCONTROLLED SUBSTANCE