Basic Information
| Provider Information | |||||||||
| NPI: | 1164556940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDWICK | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN MSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLSSEN | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | ALEX | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN BSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2406 TUMBLEWEED TRL | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204346142 | ||||||||
| FaxNumber: | 9208452128 | ||||||||
| Practice Location | |||||||||
| Address1: | N6185 SCHOOL CREEK TRL | ||||||||
| Address2: | |||||||||
| City: | LUXEMBERG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208452128 | ||||||||
| FaxNumber: | 9208452128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | WI | X | Nursing Service Providers | Registered Nurse | Home Health | 163W00000X | WI | X | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 35016200 | 05 | WI | MEDICAID |