Provider Demographics
NPI:1396203543
Name:MELVIN, MALLORY LYNN
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNN
Last Name:MELVIN
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 1:9640 RANGELINE RD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-9100
Mailing Address - Country:US
Mailing Address - Phone:715-965-2752
Mailing Address - Fax:
Practice Address - Street 1:105 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4811
Practice Address - Country:US
Practice Address - Phone:715-965-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program