NPIMap

Individual provider Active NPI

Melissa Ann Wallace, CRNP

  • Family Nurse Practitioner
  • State College, PA
National Provider Identifier
1023524501
Registry record updated Nov 7, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
SP018172 Issued in PA
Practice address
905 University Dr
State College, PA 16801-6626
Phone
(814) 238-8418
Fax
(814) 234-2888
NPI assigned
Dec 20, 2017
Last updated
Nov 7, 2019By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 7, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X SP018172 PA Primary

Addresses

Primary practice location

905 University Dr
State College, PA 16801-6626

Mailing address

905 University Dr
State College, PA 16801-6626
Phone (814) 238-8418

Other names 1

  • Melissa Ann Boetel Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA, SD2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20180122000897 PA Practitioner - Nurse Practitioner 9830458850 Reassigns benefits to 1 organization
I20250909001413 SD Practitioner - Nurse Practitioner 9830458850 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

2805 5TH St
Rapid City, SD 57701-6003
Phone (605) 755-5700

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
SP018172PAMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Monument Health Rapid City Hospital Inc CurrentSince Jun 13, 2025 Accepting new patients
Monument Health Rapid City Hospital, Inc Current Accepting new patients
Monument Health Rapid City Hospital, Inc CurrentSince Jun 13, 2025 Accepting new patients
Mount Nittany Medical Center Health Services Inc CurrentSince Jan 8, 2018 Accepting new patients
Windber Hospital, Inc. Past Accepting new patients
Monument Health Rapid City Hospital, Inc. Past Accepting new patients

Locations

141 Medical Park Ln
Bellefonte, PA 16823
Phone (814) 355-7322

164 Greenview Dr
State College, PA 16803
Phone (814) 278-4631

1850 E Park Ave
Ste 201
State College, PA 16803
Phone (814) 234-8800

2520 Green Tech Dr
Ste C
State College, PA 16803
Phone (814) 278-4898

905 University Dr
State College, PA 16801
Phone (814) 237-3122

2805 5th St
Rapid City, SD 57701
Phone (605) 719-5650

2805 5th St
Ste 100
Rapid City, SD 57701
Phone (605) 719-5700

353 Fairmont Blvd
Rapid City, SD 57701
Phone (605) 719-1000

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 28

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 28

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1513728000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1573084800000",
    "number": "1023524501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "905 UNIVERSITY DR",
            "city": "STATE COLLEGE",
            "state": "PA",
            "postal_code": "168016626",
            "telephone_number": "814-238-8418",
            "fax_number": "814-234-2888"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "905 UNIVERSITY DR",
            "city": "STATE COLLEGE",
            "state": "PA",
            "postal_code": "168016626",
            "telephone_number": "814-238-8418",
            "fax_number": "814-234-2888"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MELISSA",
        "middle_name": "ANN",
        "credential": "CRNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-12-20",
        "last_updated": "2019-11-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "PA",
            "license": "SP018172",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MELISSA",
            "last_name": "BOETEL",
            "middle_name": "ANN",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in State College, PA

Sources for this page

Verify at the official NPI Registry.