Provider Demographics
NPI:1053857474
Name:PORTELA, MELISSA (AT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PORTELA
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:RIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25250 N 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-4335
Mailing Address - Country:US
Mailing Address - Phone:623-445-7193
Mailing Address - Fax:
Practice Address - Street 1:25250 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-4335
Practice Address - Country:US
Practice Address - Phone:623-445-7193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator