Provider Demographics
NPI:1497239800
Name:BURGESS, MELISSA A (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 NORTHDALE BLVD NW STE 220
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3046
Mailing Address - Country:US
Mailing Address - Phone:763-537-6000
Mailing Address - Fax:
Practice Address - Street 1:9550 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4481
Practice Address - Country:US
Practice Address - Phone:763-537-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily