Provider Demographics
NPI:1205441052
Name:RAQUET, MELODY ANN
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:ANN
Last Name:RAQUET
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 1:7124 COMMONS DR UNIT D
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2620
Mailing Address - Country:US
Mailing Address - Phone:307-635-6777
Mailing Address - Fax:
Practice Address - Street 1:7124 COMMONS DR UNIT D
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-2620
Practice Address - Country:US
Practice Address - Phone:307-635-6777
Practice Address - Fax:307-635-6780
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCO260756225X00000X
WYOL-21-41284225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY21-41284OtherCITY LICENSE