Provider Demographics
NPI:1699234609
Name:BOLLES, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOLLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 WHITEWATER DR
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9438
Mailing Address - Country:US
Mailing Address - Phone:612-289-2385
Mailing Address - Fax:844-897-5371
Practice Address - Street 1:12700 WHITEWATER DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9438
Practice Address - Country:US
Practice Address - Phone:612-289-2385
Practice Address - Fax:844-897-5371
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6493363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health