Basic Information
| Provider Information | |||||||||
| NPI: | 1346737608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLAISTED | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICKELSEN | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 277381 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303847381 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296111 | ||||||||
| FaxNumber: | 2085297021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2018 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 58030 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 58030 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.