Provider Demographics
NPI:1093322273
Name:DAHLSTROM, MELISSA JO
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JO
Last Name:DAHLSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 HIDDEN VLY
Mailing Address - Street 2:
Mailing Address - City:MINNESOTA CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55959-1231
Mailing Address - Country:US
Mailing Address - Phone:507-429-8902
Mailing Address - Fax:
Practice Address - Street 1:185 HIDDEN VLY
Practice Address - Street 2:
Practice Address - City:MINNESOTA CITY
Practice Address - State:MN
Practice Address - Zip Code:55959-1231
Practice Address - Country:US
Practice Address - Phone:507-429-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR768175844521172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver