Healthcare Provider Details

I. General information

NPI: 1649588914
Provider Name (Legal Business Name): MELISSA N MILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA N LIND PA-C

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 N PARK DRIVE LN
APPLETON WI
54911-1603
US

IV. Provider business mailing address

2809 N PARK DRIVE LN
APPLETON WI
54911-1603
US

V. Phone/Fax

Practice location:
  • Phone: 920-380-4999
  • Fax:
Mailing address:
  • Phone: 920-380-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003857
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4250
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: