Provider Demographics
NPI:1497056444
Name:MANCZAK, MELISSA ANN (MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:MANCZAK
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39190 RIVERCREST AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-1918
Mailing Address - Country:US
Mailing Address - Phone:734-347-5707
Mailing Address - Fax:
Practice Address - Street 1:7001 ORCHARD LAKE ROAD
Practice Address - Street 2:SUITE 320C
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:OAKLAND
Practice Address - Zip Code:48322-3607
Practice Address - Country:UM
Practice Address - Phone:248-571-3600
Practice Address - Fax:248-973-8560
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253830363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383490114OtherTAX ID