Provider Demographics
NPI:1801056288
Name:DEYE, MELINDA ALICE (APNP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ALICE
Last Name:DEYE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:ALICE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:257 W SAINT GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7827
Mailing Address - Country:US
Mailing Address - Phone:715-463-5317
Mailing Address - Fax:715-463-7335
Practice Address - Street 1:257 W SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7827
Practice Address - Country:US
Practice Address - Phone:715-463-5317
Practice Address - Fax:715-463-7335
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3504-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36097300Medicaid
MN1801056288Medicaid
WI090350015Medicare PIN