Basic Information
| Provider Information | |||||||||
| NPI: | 1477672921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNER | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TEIGEN | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2701 13TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581033602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2701 13TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581033602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 49747 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 11218 | ND | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10769 | 05 | ND | MEDICAID | 108452100 | 05 | MN | MEDICAID |