Provider Demographics
NPI:1902182835
Name:PETERSON, MELISSA ANNE
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANNE
Last Name:PETERSON
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 1:3850 GRANADA WAY N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3031
Mailing Address - Country:US
Mailing Address - Phone:651-431-1797
Mailing Address - Fax:
Practice Address - Street 1:3850 GRANADA WAY N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3031
Practice Address - Country:US
Practice Address - Phone:651-431-1797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide