Provider Demographics
NPI:1679140750
Name:FAIRCHILD, MELISSA MAE (CNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MAE
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 HARRISON DR
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-4637
Mailing Address - Country:US
Mailing Address - Phone:218-259-9626
Mailing Address - Fax:218-259-9626
Practice Address - Street 1:112 1ST ST W
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-888-8032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8225363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health