Provider Demographics
NPI:1386212173
Name:MANGAN, MELISSA (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MANGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:KEMPENICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 WAYZATA BLVD E STE 110
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1984
Mailing Address - Country:US
Mailing Address - Phone:952-222-7670
Mailing Address - Fax:
Practice Address - Street 1:1120 WAYZATA BLVD E STE 110
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1984
Practice Address - Country:US
Practice Address - Phone:952-222-7670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF06211243363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner