Provider Demographics
NPI:1750555363
Name:MELTON, NICHOLE J (APRN)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:J
Last Name:MELTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:NICHOLE
Other - Middle Name:J
Other - Last Name:RADTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:335 MAHN COURT
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154
Mailing Address - Country:US
Mailing Address - Phone:414-762-2020
Mailing Address - Fax:414-762-2024
Practice Address - Street 1:3120 SOUTH 27TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-672-8282
Practice Address - Fax:414-672-8284
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152367363LA2200X
WI3606-033207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750555363Medicaid
WI1750555363Medicaid