Healthcare Provider Details

I. General information

NPI: 1174904429
Provider Name (Legal Business Name): MELISSA J WIEGAND NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BEVIER ST
SHELBY MI
49455-1209
US

IV. Provider business mailing address

PO BOX 1848
MUSKEGON MI
49443-1848
US

V. Phone/Fax

Practice location:
  • Phone: 231-861-2187
  • Fax: 231-861-5100
Mailing address:
  • Phone: 231-727-5211
  • Fax: 231-728-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704230188
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: