Provider Demographics
NPI:1063631083
Name:WIGHTMAN, MALISSA R (RN, APNP)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:R
Last Name:WIGHTMAN
Suffix:
Gender:F
Credentials:RN, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1844
Mailing Address - Country:US
Mailing Address - Phone:608-363-5500
Mailing Address - Fax:
Practice Address - Street 1:2825 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1844
Practice Address - Country:US
Practice Address - Phone:608-363-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1069363LP0200X
WI113626363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43880300Medicaid
WI43880300Medicaid
S68757Medicare UPIN