Healthcare Provider Details

I. General information

NPI: 1780118331
Provider Name (Legal Business Name): STEPHANIE JANINE MELQUIST MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE JOHNSON

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 23RD AVE S
FARGO ND
58104-7927
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-2575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number94-11088
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16786
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301514155
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number16786
License Number StateND
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRL15185
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: