Provider Demographics
NPI:1114664307
Name:KOEBERNICK, MELISSA JOY
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOY
Last Name:KOEBERNICK
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 1:13021 110TH ST
Mailing Address - Street 2:
Mailing Address - City:MENAHGA
Mailing Address - State:MN
Mailing Address - Zip Code:56464-3586
Mailing Address - Country:US
Mailing Address - Phone:218-564-5920
Mailing Address - Fax:
Practice Address - Street 1:13021 110TH ST
Practice Address - Street 2:
Practice Address - City:MENAHGA
Practice Address - State:MN
Practice Address - Zip Code:56464-3586
Practice Address - Country:US
Practice Address - Phone:218-564-5920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider