Healthcare Provider Details

I. General information

NPI: 1366307472
Provider Name (Legal Business Name): MELISSA LANGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 SMALL FARM RD
MUKWONAGO WI
53149-1463
US

IV. Provider business mailing address

503 SMALL FARM RD
MUKWONAGO WI
53149-1463
US

V. Phone/Fax

Practice location:
  • Phone: 262-289-0415
  • Fax:
Mailing address:
  • Phone: 262-289-0415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: