Provider Demographics
NPI:1164890596
Name:MELLENTHIN, MARY A (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MELLENTHIN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-5666
Mailing Address - Fax:
Practice Address - Street 1:912 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5530
Practice Address - Country:US
Practice Address - Phone:920-907-3922
Practice Address - Fax:920-929-7392
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6501-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily