Provider Demographics
NPI:1376047001
Name:WISEMAN, MELANIE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:LYNN
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:BUMBALOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PSC 455 BOX 208
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96540-0003
Mailing Address - Country:US
Mailing Address - Phone:671-344-9340
Mailing Address - Fax:
Practice Address - Street 1:BLDG #50 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-344-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101267500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine