Provider Demographics
NPI:1407450349
Name:WILLOCK, MELISSA ANNE (LPN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:WILLOCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4608 N 72ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4856
Mailing Address - Country:US
Mailing Address - Phone:414-737-3081
Mailing Address - Fax:414-231-3135
Practice Address - Street 1:3500 N SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3463
Practice Address - Country:US
Practice Address - Phone:414-737-3081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI843581865Medicaid