Provider Demographics
NPI:1215404124
Name:MELENDEZ, FANNY PAOLA
Entity Type:Individual
Prefix:
First Name:FANNY
Middle Name:PAOLA
Last Name:MELENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 RENAISSANCE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6194
Mailing Address - Country:US
Mailing Address - Phone:702-451-7542
Mailing Address - Fax:
Practice Address - Street 1:2255 RENAISSANCE DR STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6194
Practice Address - Country:US
Practice Address - Phone:702-451-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
4548926OtherMEXICAN PROFESSIONAL LICENSE
A27-11-07OtherCLINICAL PSYCHO PEDAGOGY MASTER CERTIFICATE