Provider Demographics
NPI:1609177674
Name:JOHN, MELISSA DALE (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DALE
Last Name:JOHN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:DALE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:A-GNP-C
Mailing Address - Street 1:1622 15TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3436
Mailing Address - Country:US
Mailing Address - Phone:701-590-2815
Mailing Address - Fax:701-356-1555
Practice Address - Street 1:1701 38TH ST S STE 101
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4499
Practice Address - Country:US
Practice Address - Phone:701-356-1500
Practice Address - Fax:701-356-1598
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDA363LG0600X
NDR34298363LG0600X
MNR-198861-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse