Healthcare Provider Details

I. General information

NPI: 1154507630
Provider Name (Legal Business Name): MELINDA E. WENNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 N UNIVERSITY DR
NACOGDOCHES TX
75965-2922
US

IV. Provider business mailing address

2702 N UNIVERSITY DR
NACOGDOCHES TX
75965-2922
US

V. Phone/Fax

Practice location:
  • Phone: 936-205-5805
  • Fax: 936-205-5997
Mailing address:
  • Phone: 936-205-5805
  • Fax: 936-205-5997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP1835
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: