Provider Demographics
NPI:1912389719
Name:LE, MELISSA JILL
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JILL
Last Name:LE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:JILL
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:4091 WILD GOOSE LN
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7639
Mailing Address - Country:US
Mailing Address - Phone:651-232-7599
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1674282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural