Provider Demographics
NPI:1114974987
Name:MELBY, KRISTIN LEE (FP-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LEE
Last Name:MELBY
Suffix:
Gender:F
Credentials:FP-C
Other - Prefix:MRS
Other - First Name:KRISTIN
Other - Middle Name:LEE
Other - Last Name:MELBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:701 E ROSSER AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4461
Mailing Address - Country:US
Mailing Address - Phone:701-751-9500
Mailing Address - Fax:701-751-9508
Practice Address - Street 1:701 E ROSSER AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4461
Practice Address - Country:US
Practice Address - Phone:701-751-9500
Practice Address - Fax:701-751-9508
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR25527363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19600Medicaid
ND19600Medicaid
ND16017Medicare ID - Type Unspecified