Provider Demographics
NPI:1548997992
Name:HENDRICKSON, MELISSA M (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 W ARIZONA ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-3358
Mailing Address - Country:US
Mailing Address - Phone:414-698-6114
Mailing Address - Fax:
Practice Address - Street 1:5337 W ARIZONA ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-3358
Practice Address - Country:US
Practice Address - Phone:414-698-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13059-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty