Provider Demographics
NPI:1407162092
Name:MORK, MELISSA JEAN (APNP, RN)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JEAN
Last Name:MORK
Suffix:
Gender:F
Credentials:APNP, RN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP, RN
Mailing Address - Street 1:4328 OLD GREEN BAY ROAD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403
Mailing Address - Country:US
Mailing Address - Phone:262-687-7606
Mailing Address - Fax:262-687-7615
Practice Address - Street 1:4328 OLD GREEN BAY ROAD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403
Practice Address - Country:US
Practice Address - Phone:262-687-7606
Practice Address - Fax:262-687-7615
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIAPNWI9114-33207Q00000X
TX717304363LF0000X
IL209012202363LF0000X
WI9114-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9114-33Medicaid