Provider Demographics
NPI:1699379602
Name:DECOTEAU, MELISSA MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:DECOTEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-3223
Mailing Address - Country:US
Mailing Address - Phone:701-620-9979
Mailing Address - Fax:
Practice Address - Street 1:1708 24TH AVE S APT 3
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6237
Practice Address - Country:US
Practice Address - Phone:701-215-1226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDDEC892488376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1474632Medicaid