Healthcare Provider Details

I. General information

NPI: 1316228620
Provider Name (Legal Business Name): MELISSA A KERSTEN FNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 FOREST LN
WATERFORD WI
53185-4585
US

IV. Provider business mailing address

818 FOREST LN
WATERFORD WI
53185-4585
US

V. Phone/Fax

Practice location:
  • Phone: 262-514-8199
  • Fax: 608-741-3838
Mailing address:
  • Phone: 262-514-8199
  • Fax: 608-741-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4588
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: