Provider Demographics
NPI:1447672613
Name:VEENENDAAL, MELISSA (APNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:VEENENDAAL
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BUBLITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-291-1232
Mailing Address - Fax:
Practice Address - Street 1:2301 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-291-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5299-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily