Provider Demographics
NPI:1275914988
Name:MALLOY, MELISSA (PAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:725 AMERICAN AVE STE 5
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-2475
Practice Address - Fax:262-928-5697
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant