Provider Demographics
NPI:1154382653
Name:ANDERSON, MELEA RAE (PNP)
Entity type:Individual
Prefix:
First Name:MELEA
Middle Name:RAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:3000 N CHESTNUT ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-3054
Practice Address - Country:US
Practice Address - Phone:952-361-3999
Practice Address - Fax:952-361-3995
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-132282-6363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28236Medicare UPIN