Provider Demographics
NPI:1184197568
Name:SOPER, MELANIE R (FNP-BC)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:SOPER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:WILKESON
Mailing Address - State:WA
Mailing Address - Zip Code:98396-0090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30811 QUINNON EXT RD E
Practice Address - Street 2:
Practice Address - City:WILKESON
Practice Address - State:WA
Practice Address - Zip Code:98396-1004
Practice Address - Country:US
Practice Address - Phone:906-280-3918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61317504363LP2300X
WI222244-30163W00000X
MI4704226990163W00000X
IN28251764A163W00000X
IN71009982A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28251764AOtherSTATE OF INDIANA
MI4704226990OtherSTATE OF MICHIGAN
WI222244-30OtherSTATE OF WISCONSIN