Healthcare Provider Details

I. General information

NPI: 1083522619
Provider Name (Legal Business Name): MELISSA SHIDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 NIAGARA LN N STE 100
MAPLE GROVE MN
55369-7588
US

IV. Provider business mailing address

13711 MARIGOLD WAY
ROGERS MN
55374-8854
US

V. Phone/Fax

Practice location:
  • Phone: 763-297-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR184599-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: