Basic Information
| Provider Information | |||||||||
| NPI: | 1588041891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWIERAD | ||||||||
| FirstName: | MELISSA | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6308 8TH AVENUE | ||||||||
| Address2: | ATTN: MED. STAFF OFFICE | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531535031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626563313 | ||||||||
| FaxNumber: | 2626535850 | ||||||||
| Practice Location | |||||||||
| Address1: | 6308 8TH AVE STE 3040 | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531435031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626535483 | ||||||||
| FaxNumber: | 2626563830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 209012706 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363L00000X | 7980-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 209012706 | 05 | IL | MEDICAID |