Provider Demographics
NPI:1902436447
Name:CLISCH, MELISSA (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CLISCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43821 FORD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3122
Mailing Address - Country:US
Mailing Address - Phone:734-656-1021
Mailing Address - Fax:734-656-1022
Practice Address - Street 1:43821 FORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3122
Practice Address - Country:US
Practice Address - Phone:734-656-1021
Practice Address - Fax:734-656-1022
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704316144363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner