1932379658 NPI number — MELISSA A. MCKINNEY, D.O., P.L.L.C.

Table of content: (NPI 1932379658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932379658 NPI number — MELISSA A. MCKINNEY, D.O., P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELISSA A. MCKINNEY, D.O., P.L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932379658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2370 W HWY 89A #11 PMB 412
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEDONA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86336-5341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-592-9140
Provider Business Mailing Address Fax Number:
928-592-9144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4283 PIMA WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE MONTEZUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86342-5087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-592-9140
Provider Business Practice Location Address Fax Number:
928-592-9144
Provider Enumeration Date:
03/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCKINNEY
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
928-592-9140

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  4057 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z104516 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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