Provider Demographics
NPI:1053026070
Name:FOFANA, MELISSA MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:FOFANA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 38TH ST S STE 101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4499
Mailing Address - Country:US
Mailing Address - Phone:701-356-1500
Mailing Address - Fax:701-356-1596
Practice Address - Street 1:1701 38TH ST S STE 101
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4499
Practice Address - Country:US
Practice Address - Phone:701-356-1500
Practice Address - Fax:701-356-1596
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2367107163W00000X
MN9983363LF0000X
NDR38049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1488848Medicaid
MN1053026070Medicaid