Healthcare Provider Details

I. General information

NPI: 1609513654
Provider Name (Legal Business Name): MELANIE MARY QUEENER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 CLEVELAND RD
WOOSTER OH
44691-2204
US

IV. Provider business mailing address

1740 CLEVELAND RD
WOOSTER OH
44691-2204
US

V. Phone/Fax

Practice location:
  • Phone: 330-287-4500
  • Fax:
Mailing address:
  • Phone: 330-287-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.007740RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: