Provider Demographics
NPI:1841763398
Name:CHRISTIANSON, MELISSA (RN BSN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ROAD 6193
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-9328
Mailing Address - Country:US
Mailing Address - Phone:505-486-9020
Mailing Address - Fax:
Practice Address - Street 1:550 ROAD 6100
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:NM
Practice Address - Zip Code:87417-9317
Practice Address - Country:US
Practice Address - Phone:505-598-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM291090163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM291090OtherNEW MEXICO PUBLIC EDUCATION DEPARTMENT
NM543567OtherREGISTERED NURSE