MEDICARE: MELISSA WANSERSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	83480784405	UT

General Provider Information

NPI Number	:	1174916571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA WANSERSKI

Provider Business Mailing Address
First Line	:	2795 E KENTON DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2068
Country	:	US
Telephone Number	:	715-432-9211
Fax Number	:

Provider Business Practice Location Address
First Line	:	2795 E KENTON DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2068
Country	:	US
Telephone Number	:	715-432-9211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2015
Last Update Date	:	03/09/2015

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Directions to “ MELISSA WANSERSKI ” Practice Location

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