Basic Information
| Provider Information | |||||||||
| NPI: | 1003401753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELENDEZ | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3728 VILAS RD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535279450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8722201234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 YORDON CENTER | ||||||||
| Address2: | |||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157530211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2021 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.