Provider Demographics
NPI:1760474258
Name:HANSEN, MELISSA (CPNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14135 CEDAR AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4522
Mailing Address - Country:US
Mailing Address - Phone:952-432-4373
Mailing Address - Fax:952-997-5679
Practice Address - Street 1:14135 CEDAR AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4522
Practice Address - Country:US
Practice Address - Phone:952-432-4373
Practice Address - Fax:952-997-5679
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR115625-4363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN605323800Medicaid
MNS98508Medicare UPIN