Healthcare Provider Details

I. General information

NPI: 1093322273
Provider Name (Legal Business Name): MELISSA JO DAHLSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 10/04/2020
Certification Date: 10/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 HIDDEN VLY
MINNESOTA CITY MN
55959-1231
US

IV. Provider business mailing address

185 HIDDEN VLY
MINNESOTA CITY MN
55959-1231
US

V. Phone/Fax

Practice location:
  • Phone: 507-429-8902
  • Fax:
Mailing address:
  • Phone: 507-429-8902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberR768175844521
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: