Provider Demographics
NPI:1770683963
Name:MAKI, MELISSA ANN (PMHNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MAKI
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 MILLER TRUNK HWY STE 214
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4443
Mailing Address - Country:US
Mailing Address - Phone:218-727-3888
Mailing Address - Fax:218-260-4772
Practice Address - Street 1:4899 MILLER TRUNK HWY STE 208
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1582
Practice Address - Country:US
Practice Address - Phone:218-727-3888
Practice Address - Fax:218-260-4772
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR128720-4363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN034023500Medicaid
MN034023500Medicaid