Healthcare Provider Details

I. General information

NPI: 1093173064
Provider Name (Legal Business Name): MELANIE IMKER WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

20018 INDIAN LAKE RD
MANKATO MN
56001-6617
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-4031
  • Fax:
Mailing address:
  • Phone: 651-325-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR-192262-4
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 1924
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704290170
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: