Provider Demographics
NPI:1366483554
Name:FACKLER, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:FACKLER
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 1:5000 CHESHIRE LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3706
Mailing Address - Country:US
Mailing Address - Phone:888-333-9152
Mailing Address - Fax:763-268-4240
Practice Address - Street 1:2300 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2971
Practice Address - Country:US
Practice Address - Phone:765-447-0131
Practice Address - Fax:765-446-8168
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001121A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist