Provider Demographics
NPI:1902041619
Name:MILLER, MELISSA MARY (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:MARY
Last Name:MILLER
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:N1508 SHARI LN
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-9381
Mailing Address - Country:US
Mailing Address - Phone:920-723-1823
Mailing Address - Fax:
Practice Address - Street 1:N1508 SHARI LN
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-9381
Practice Address - Country:US
Practice Address - Phone:920-723-1823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306805-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35061500Medicaid