Basic Information
| Provider Information | |||||||||
| NPI: | 1104540012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELZARK | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | LEAH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLTON | ||||||||
| OtherFirstName: | CHRISTY | ||||||||
| OtherMiddleName: | LEAH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 62 | ||||||||
| Address2: | |||||||||
| City: | ASKOV | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557040062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202797287 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 LUNDORFF DR UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2022 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9580 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.