Provider Demographics
NPI:1316337389
Name:FEDDEMA, MELANIE ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:FEDDEMA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 ROOSEVELT RD
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-6269
Mailing Address - Country:US
Mailing Address - Phone:320-229-4069
Mailing Address - Fax:320-229-4071
Practice Address - Street 1:3315 ROOSEVELT RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6269
Practice Address - Country:US
Practice Address - Phone:320-229-4069
Practice Address - Fax:320-229-4071
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104707225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist