Provider Demographics
NPI:1679782700
Name:WILLMING, MELLISSA C (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:C
Last Name:WILLMING
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5918
Mailing Address - Country:US
Mailing Address - Phone:920-843-5873
Mailing Address - Fax:414-622-3869
Practice Address - Street 1:320 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5918
Practice Address - Country:US
Practice Address - Phone:920-843-5973
Practice Address - Fax:414-622-3869
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7680-33363LF0000X
WI7680363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100067789Medicaid