Basic Information
Provider Information | |||||||||
NPI: | 1245584564 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JANSSEN | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANRP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GERLACH | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3178 | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524063178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193981583 | ||||||||
FaxNumber: | 3193992085 | ||||||||
Practice Location | |||||||||
Address1: | 202 10TH STREET SE | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524032404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193992022 | ||||||||
FaxNumber: | 3193992014 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2012 | ||||||||
LastUpdateDate: | 10/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A-118348 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A118348 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 0210978 | 05 | IA |   | MEDICAID |