Provider Demographics
NPI:1407480932
Name:BOLTZE, MELANIE LEE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:LEE
Last Name:BOLTZE
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 1:12409 W INDIAN SCHOOL RD STE B210
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-9505
Mailing Address - Country:US
Mailing Address - Phone:623-935-9920
Mailing Address - Fax:
Practice Address - Street 1:12409 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-9502
Practice Address - Country:US
Practice Address - Phone:623-935-9920
Practice Address - Fax:623-935-9925
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ165689163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice