Healthcare Provider Details

I. General information

NPI: 1043007974
Provider Name (Legal Business Name): MEGUMI MELDRUM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGUMI MELDRUM KELLEY

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 S VAN BUREN ST STE 201
GREEN BAY WI
54301-3534
US

IV. Provider business mailing address

7516 FAIRVIEW RD
OCONTO WI
54153-9757
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-7488
  • Fax:
Mailing address:
  • Phone: 630-802-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17024-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number1110701-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: