Healthcare Provider Details

I. General information

NPI: 1760008619
Provider Name (Legal Business Name): MELANIE NIELSEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S73W16437 JANESVILLE RD
MUSKEGO WI
53150-9723
US

IV. Provider business mailing address

PO BOX 547
MUSKEGO WI
53150-0547
US

V. Phone/Fax

Practice location:
  • Phone: 414-422-0300
  • Fax:
Mailing address:
  • Phone: 262-679-1420
  • Fax: 414-422-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3621-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: