Provider Demographics
NPI:1497036826
Name:PROFFITT, MELINDA CHARLENE (LPN)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:CHARLENE
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17028 W CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-1301
Mailing Address - Country:US
Mailing Address - Phone:623-876-7704
Mailing Address - Fax:623-876-7711
Practice Address - Street 1:13700 W GREENWAY RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-5291
Practice Address - Country:US
Practice Address - Phone:623-876-7704
Practice Address - Fax:623-876-7711
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP039849164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse