Healthcare Provider Details

I. General information

NPI: 1629891809
Provider Name (Legal Business Name): MELANIE FASANO APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 BIG BEND RD
WAUKESHA WI
53189-7624
US

IV. Provider business mailing address

2130 BIG BEND RD
WAUKESHA WI
53189-7624
US

V. Phone/Fax

Practice location:
  • Phone: 262-928-7555
  • Fax: 262-928-7575
Mailing address:
  • Phone: 262-928-7555
  • Fax: 262-928-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16143-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: