Provider Demographics
NPI:1477672921
Name:HORNER, MELISSA MARIE (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:HORNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:TEIGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2701 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3602
Mailing Address - Country:US
Mailing Address - Phone:701-234-3620
Mailing Address - Fax:
Practice Address - Street 1:2701 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3602
Practice Address - Country:US
Practice Address - Phone:701-234-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN49747208000000X
ND11218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10769Medicaid
MN108452100Medicaid
MN370003368Medicare PIN
NDN714474Medicare PIN
ND10769Medicaid