Provider Demographics
NPI:1558108688
Name:BOLDT, MELISSA LYNN (FNP-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:BOLDT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 SHADY LAWN CIR
Mailing Address - Street 2:
Mailing Address - City:SOBIESKI
Mailing Address - State:WI
Mailing Address - Zip Code:54171-4403
Mailing Address - Country:US
Mailing Address - Phone:920-819-7775
Mailing Address - Fax:
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15573-33207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services