Healthcare Provider Details

I. General information

NPI: 1285335679
Provider Name (Legal Business Name): NICOLE AMBER MEISSNER AGNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 S ALVERNO RD
MANITOWOC WI
54220-9340
US

IV. Provider business mailing address

2409 S ALVERNO RD
MANITOWOC WI
54220-9340
US

V. Phone/Fax

Practice location:
  • Phone: 920-901-4420
  • Fax: 920-682-4243
Mailing address:
  • Phone: 920-901-4420
  • Fax: 920-682-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number13955-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number196585-30
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: