Basic Information
| Provider Information | |||||||||
| NPI: | 1659902864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLINTOCK | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | N 10 RIVER ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT YATES | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58538 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2020 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R44546 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.