Provider Demographics
NPI:1225636459
Name:WETTSTEIN, MELANIE JOANN
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:JOANN
Last Name:WETTSTEIN
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 1:5027 EVERGREEN DR N UNIT 3
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8578
Mailing Address - Country:US
Mailing Address - Phone:612-715-4816
Mailing Address - Fax:
Practice Address - Street 1:5027 EVERGREEN DR N UNIT 3
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-8578
Practice Address - Country:US
Practice Address - Phone:612-715-4816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1105351175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist