Provider Demographics
NPI:1023667409
Name:EBBEN, MELISSA (APNP, FNP-BC, SANE-A)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:EBBEN
Suffix:
Gender:F
Credentials:APNP, FNP-BC, SANE-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 W TWIN WILLOW CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-6648
Mailing Address - Country:US
Mailing Address - Phone:920-450-3285
Mailing Address - Fax:
Practice Address - Street 1:3325 W TWIN WILLOW CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-6648
Practice Address - Country:US
Practice Address - Phone:920-450-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60455694163W00000X
WI9631-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse