=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528677572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA KOEHL NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2020
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 S CASCADE ST
-----------------------------------------------------
City | FERGUS FALLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56537-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-736-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28196 500TH AVE
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56267-4363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-287-0269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 7581
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------