Provider Demographics
NPI:1659902864
Name:MCCLINTOCK, MELISSA RENAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENAE
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N 10 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR44546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily