Healthcare Provider Details

I. General information

NPI: 1265942353
Provider Name (Legal Business Name): MELANIE MICHELLE KIZZIAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DRIVE 330
FORT WAYNE IN
46845-4684
US

IV. Provider business mailing address

1535 BEAR CLAW LANE
FORT WAYNE IN
46845
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-5114
  • Fax: 260-471-5114
Mailing address:
  • Phone: 260-450-9329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License Number28221817A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License Number28221817A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: