Healthcare Provider Details

I. General information

NPI: 1639795578
Provider Name (Legal Business Name): MELISSA WEITEKAMP MS CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 WILSON PIKE CIRCLE
BRENTWOOD TN
37027
US

IV. Provider business mailing address

421 LIBERTY PIKE APT 201
FRANKLIN TN
37064-3196
US

V. Phone/Fax

Practice location:
  • Phone: 615-236-6566
  • Fax:
Mailing address:
  • Phone: 262-993-6714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00117025
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: