Provider Demographics
NPI:1730376336
Name:TRUDELL, MELISSA ELEANOR (LMT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ELEANOR
Last Name:TRUDELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 VALLEY VISTA CT SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2862
Mailing Address - Country:US
Mailing Address - Phone:505-440-3063
Mailing Address - Fax:505-892-8794
Practice Address - Street 1:1810 INCA RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5309
Practice Address - Country:US
Practice Address - Phone:505-440-3063
Practice Address - Fax:505-892-8794
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1538174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM275119OtherABMP
NM1538OtherNM BOARD MASSAGE THERAPY
NM3359OtherNCTMB