Provider Demographics
NPI:1184010852
Name:MELLEN, GRACE MARIE (RN / NP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MARIE
Last Name:MELLEN
Suffix:
Gender:F
Credentials:RN / NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E. MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2611
Mailing Address - Country:US
Mailing Address - Phone:602-258-4951
Mailing Address - Fax:602-340-1853
Practice Address - Street 1:10585 N TATUM BLVD
Practice Address - Street 2:SUITE D130
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1073
Practice Address - Country:US
Practice Address - Phone:602-997-7263
Practice Address - Fax:602-944-4553
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN120100163W00000X
AZAP7444363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health