Provider Demographics
NPI:1235572744
Name:MELNICK, STACEY WAYNE (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:WAYNE
Last Name:MELNICK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 SW MARLOW AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5102
Mailing Address - Country:US
Mailing Address - Phone:503-430-1777
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE STE 202
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-430-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350068NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health