Provider Demographics
NPI:1336121094
Name:LOGUE, MELANIE DANE (PHD, DNP, APRN, CFNP)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:DANE
Last Name:LOGUE
Suffix:
Gender:F
Credentials:PHD, DNP, APRN, CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11575 W CANDELILLA WAY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-4556
Mailing Address - Country:US
Mailing Address - Phone:235-232-7656
Mailing Address - Fax:
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084
Practice Address - Country:US
Practice Address - Phone:308-500-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN083247163W00000X
CARN95148897163W00000X
CANP95008920363LF0000X
CANPF95008920363LF0000X
AZAP0835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ490699Medicaid
AZ490699Medicaid