Provider Demographics
NPI:1790451540
Name:MELLESMOEN, KAITLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MELLESMOEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:DAGGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7400 FRANCE AVE S
Mailing Address - Street 2:STE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4738
Mailing Address - Country:US
Mailing Address - Phone:763-537-6000
Mailing Address - Fax:763-537-6666
Practice Address - Street 1:7400 FRANCE AVE S # A
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4738
Practice Address - Country:US
Practice Address - Phone:612-708-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13559363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1166361OtherNCCPA
MN13559OtherMN BOARD OF MEDICAL PRACTICE PA LICENSURE