Provider Demographics
NPI:1962051359
Name:BRUSACORAM, MELISSA SUE (APRN, CNP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:SUE
Last Name:BRUSACORAM
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7478 GREEN ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SIDE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55781-8434
Mailing Address - Country:US
Mailing Address - Phone:218-296-0688
Mailing Address - Fax:
Practice Address - Street 1:118 W LAKE ST
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1819
Practice Address - Country:US
Practice Address - Phone:218-254-0101
Practice Address - Fax:844-921-1071
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2100555163WP0808X
MN7331363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty