Healthcare Provider Details

I. General information

NPI: 1093037798
Provider Name (Legal Business Name): MELANIE L PEQUIGNOT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE L MILLIKAN P.A.

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W JEFFERSON BLVD STE 110
FORT WAYNE IN
46804-4159
US

IV. Provider business mailing address

7910 W JEFFERSON BLVD STE 110
FORT WAYNE IN
46804-4159
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-4116
  • Fax: 260-436-1878
Mailing address:
  • Phone: 260-436-4116
  • Fax: 260-436-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001156
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: