Provider Demographics
NPI:1861113961
Name:NIEMIEC, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:NIEMIEC
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 1:3303 S BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-346-1500
Mailing Address - Fax:
Practice Address - Street 1:1300 YALE PL APT 314
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2160
Practice Address - Country:US
Practice Address - Phone:630-877-3947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA222339363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program