Provider Demographics
NPI:1467813857
Name:KOENGETER, MELISSA (APNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KOENGETER
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3430 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-9001
Mailing Address - Country:US
Mailing Address - Phone:715-804-7500
Mailing Address - Fax:
Practice Address - Street 1:3430 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-9001
Practice Address - Country:US
Practice Address - Phone:715-804-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6864-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI90503-30OtherRN LICENSE