Provider Demographics
NPI:1376414466
Name:ELLIS, MELANIE AMANDA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:AMANDA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0097
Mailing Address - Country:US
Mailing Address - Phone:920-229-0686
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 97
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-0097
Practice Address - Country:US
Practice Address - Phone:920-229-0686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-13
Last Update Date:2025-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17426-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health