Healthcare Provider Details

I. General information

NPI: 1770491292
Provider Name (Legal Business Name): MELYSE BLANDINE ISHIMWE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N HICKORY RD
SOUTH BEND IN
46615-3723
US

IV. Provider business mailing address

1005 N HICKORY RD
SOUTH BEND IN
46615-3723
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-5754
  • Fax: 574-233-7406
Mailing address:
  • Phone: 574-233-5754
  • Fax: 574-233-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number99138470A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: