Provider Demographics
NPI:1710202577
Name:DERCKS, MELISSA A (APNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:DERCKS
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:725 S WEBSTER AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-430-7100
Practice Address - Fax:920-430-7114
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4010-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2010002130OtherAMERICAN NURSES CREDENTIALING CENTER
WI4010-33OtherLICENSE
WIK400187168Medicare Oscar/Certification
WIK400229375Medicare Oscar/Certification
WI4010-33OtherLICENSE
WI002150249Medicare Oscar/Certification