Provider Demographics
NPI:1881134054
Name:FREDERICK, MELISSA BRYNN (NP-C)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:BRYNN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:BRYNN
Other - Last Name:GRABOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6901 W EDGERTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4420
Mailing Address - Country:US
Mailing Address - Phone:414-325-5244
Mailing Address - Fax:
Practice Address - Street 1:6901 W EDGERTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4420
Practice Address - Country:US
Practice Address - Phone:414-421-8400
Practice Address - Fax:414-421-9557
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7575363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100066382Medicaid