Provider Demographics
NPI:1750656252
Name:THOMPSON, MELONIE
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:
Last Name:THOMPSON
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 1:250 E 300 S
Mailing Address - Street 2:SUITE 380
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2418
Mailing Address - Country:US
Mailing Address - Phone:801-994-1466
Mailing Address - Fax:801-994-1467
Practice Address - Street 1:250 E 300 S
Practice Address - Street 2:SUITE 380
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2418
Practice Address - Country:US
Practice Address - Phone:801-994-1466
Practice Address - Fax:801-994-1467
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7265337-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily