Provider Demographics
NPI:1679831655
Name:NOWICKI, MELISSA RENEE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:NOWICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:RENEE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-645-1808
Mailing Address - Fax:
Practice Address - Street 1:3305 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4940
Practice Address - Country:US
Practice Address - Phone:414-645-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4775-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100003355Medicaid