=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366483554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE FACKLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 11/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 SOUTH ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-2971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-447-0131
-----------------------------------------------------
Fax | 765-446-8168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 CHESHIRE LN N
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55446-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-333-9152
-----------------------------------------------------
Fax | 763-268-4240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 17001121A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------