Provider Demographics
NPI:1154724144
Name:GRISAFFE, MELISSA DIANE (AGACNP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:DIANE
Last Name:GRISAFFE
Suffix:
Gender:F
Credentials:AGACNP
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 251420
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1420
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-5200
Practice Address - Fax:417-820-5220
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014022681363LA2100X, 363LA2200X
ARA004218363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154724144Medicaid
MO1154724144Medicaid