Provider Demographics
NPI:1629309752
Name:GENTZ, MELISSA G (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:G
Last Name:GENTZ
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 1:2617 HARVARD DR APT 7
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2764
Mailing Address - Country:US
Mailing Address - Phone:608-728-2656
Mailing Address - Fax:
Practice Address - Street 1:2617 HARVARD DR APT 7
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2764
Practice Address - Country:US
Practice Address - Phone:608-728-2656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309243-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI309243-031OtherLPN