Provider Demographics
NPI:1164224788
Name:MICHEALS, MELONY LEE
Entity type:Individual
Prefix:
First Name:MELONY
Middle Name:LEE
Last Name:MICHEALS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 WEDGEWOOD LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2645
Mailing Address - Country:US
Mailing Address - Phone:612-385-1914
Mailing Address - Fax:
Practice Address - Street 1:4200 WEDGEWOOD LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2645
Practice Address - Country:US
Practice Address - Phone:612-385-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1123115253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency