Healthcare Provider Details

I. General information

NPI: 1194580902
Provider Name (Legal Business Name): MELISSA KUCERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 MAIN ST
LANDER WY
82520-3145
US

IV. Provider business mailing address

431 MAIN ST
LANDER WY
82520-3145
US

V. Phone/Fax

Practice location:
  • Phone: 307-206-1161
  • Fax: 307-206-1160
Mailing address:
  • Phone: 307-206-1161
  • Fax: 307-206-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: