Provider Demographics
NPI:1427081157
Name:BONEY-WEGMANN, MELISSA DAWN (DC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:BONEY-WEGMANN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:DAWN
Other - Last Name:WEGMANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:309 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-2111
Mailing Address - Country:US
Mailing Address - Phone:309-734-2447
Mailing Address - Fax:309-734-0749
Practice Address - Street 1:309 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-2111
Practice Address - Country:US
Practice Address - Phone:309-734-2447
Practice Address - Fax:309-734-0749
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038008005Medicaid
U62662Medicare UPIN
IL038008005Medicaid
K03454Medicare ID - Type Unspecified