Provider Demographics
NPI:1578751806
Name:MACDOUGALL, MELINDA S (FNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:S
Last Name:MACDOUGALL
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 1:105 EVERETT CT
Mailing Address - Street 2:
Mailing Address - City:SHADY SHORES
Mailing Address - State:TX
Mailing Address - Zip Code:76208-5009
Mailing Address - Country:US
Mailing Address - Phone:214-952-0827
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:214-952-0827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2157352363LF0000X
TXAP112483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXY5244ZMedicare UPIN