Healthcare Provider Details

I. General information

NPI: 1407162092
Provider Name (Legal Business Name): MELISSA JEAN MORK APNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA JEAN COLLINS APNP, RN

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4328 OLD GREEN BAY ROAD
MOUNT PLEASANT WI
53403
US

IV. Provider business mailing address

4328 OLD GREEN BAY ROAD
MOUNT PLEASANT WI
53403
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-7606
  • Fax: 262-687-7615
Mailing address:
  • Phone: 262-687-7606
  • Fax: 262-687-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPNWI9114-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number717304
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012202
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9114-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: