Healthcare Provider Details

I. General information

NPI: 1023488186
Provider Name (Legal Business Name): MELANIE J WEESIES ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 MAYAPPLE LN APT 32
JACKSON MI
49201-7199
US

IV. Provider business mailing address

3417 MAYAPPLE LN APT 32
JACKSON MI
49201-7199
US

V. Phone/Fax

Practice location:
  • Phone: 231-720-5057
  • Fax:
Mailing address:
  • Phone: 231-720-5057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002305
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: