Provider Demographics
NPI:1114297215
Name:BORDENAVE, MELISSA ANNE (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:BORDENAVE
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 12TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1922
Mailing Address - Country:US
Mailing Address - Phone:651-464-0112
Mailing Address - Fax:
Practice Address - Street 1:1795 RADIO DR
Practice Address - Street 2:SUITE D
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9414
Practice Address - Country:US
Practice Address - Phone:651-696-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBOR104320461363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health