Provider Demographics
NPI:1659157519
Name:MEYER, MELINDA RAE (A11629)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:RAE
Last Name:MEYER
Suffix:
Gender:F
Credentials:A11629
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20554 JUNO TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8896
Mailing Address - Country:US
Mailing Address - Phone:612-247-7184
Mailing Address - Fax:
Practice Address - Street 1:20554 JUNO TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8896
Practice Address - Country:US
Practice Address - Phone:612-247-7184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA11629225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant