Provider Demographics
NPI:1821499740
Name:ALTMAN, MELINDA HOLLY (ARNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:HOLLY
Last Name:ALTMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N7135 ROCKY KNOLL PKWY
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-3103
Mailing Address - Country:US
Mailing Address - Phone:630-571-8990
Mailing Address - Fax:
Practice Address - Street 1:N7135 ROCKY KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-3103
Practice Address - Country:US
Practice Address - Phone:630-571-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA097345363LP2300X
WI11869363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100202310Medicaid