Provider Demographics
NPI:1508020827
Name:DAVIS, MELISSA MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:STALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:PLANKINTON
Mailing Address - State:SD
Mailing Address - Zip Code:57368-0035
Mailing Address - Country:US
Mailing Address - Phone:605-299-8234
Mailing Address - Fax:605-799-1165
Practice Address - Street 1:104 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:PLANKINTON
Practice Address - State:SD
Practice Address - Zip Code:57368
Practice Address - Country:US
Practice Address - Phone:605-299-8234
Practice Address - Fax:605-799-1165
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1489646363L00000X
SDCP000552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS103263Medicare PIN