Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 63799 | WI |
NPI | 1114362654 |
---|---|
Provider Name | Melanie Boly |
First Address | Madison, WI 53792-0001 |
Second Address | Madison, WI 53792-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2013 |
Last Update Date | 05/01/2021 |