Provider Demographics
NPI:1235837865
Name:VAN FOSSEN, MELISSA (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10715 BRIGGS CACHE CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8194
Mailing Address - Country:US
Mailing Address - Phone:406-531-6815
Mailing Address - Fax:
Practice Address - Street 1:510 W TUDOR RD STE 1
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6649
Practice Address - Country:US
Practice Address - Phone:907-744-1944
Practice Address - Fax:907-921-7669
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK203486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily