Provider Demographics
NPI:1639226483
Name:DEMELLO, MARIE THERESE (MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:THERESE
Last Name:DEMELLO
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18199 W MACKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-5234
Mailing Address - Country:US
Mailing Address - Phone:586-873-3473
Mailing Address - Fax:
Practice Address - Street 1:1661 E CAMELBACK RD STE 270
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3922
Practice Address - Country:US
Practice Address - Phone:888-777-1945
Practice Address - Fax:805-413-9099
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid