Provider Demographics
NPI:1376831180
Name:MELVILLE, STACY L (NP-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:MELVILLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10107 RIDGEGATE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5641
Mailing Address - Country:US
Mailing Address - Phone:303-925-0700
Mailing Address - Fax:303-329-2599
Practice Address - Street 1:10107 RIDGEGATE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5641
Practice Address - Country:US
Practice Address - Phone:303-925-0700
Practice Address - Fax:303-329-2599
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0001408-C-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283727001Medicaid
TXTXB135156Medicare PIN