Healthcare Provider Details

I. General information

NPI: 1962051359
Provider Name (Legal Business Name): MELISSA SUE BRUSACORAM APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 W LAKE ST
CHISHOLM MN
55719-1819
US

IV. Provider business mailing address

7478 GREEN ROCK RD
SIDE LAKE MN
55781-8434
US

V. Phone/Fax

Practice location:
  • Phone: 218-254-0101
  • Fax: 844-921-1071
Mailing address:
  • Phone: 218-296-0688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2100555
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7331
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: