Provider Demographics
NPI:1780638973
Name:STANFORD, MELINDA J (FNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:J
Last Name:STANFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:450 WILLIAMS WAY
Mailing Address - Street 2:PO BOX 998
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2065
Mailing Address - Country:US
Mailing Address - Phone:435-719-3508
Mailing Address - Fax:435-719-3509
Practice Address - Street 1:476 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2065
Practice Address - Country:US
Practice Address - Phone:435-719-5500
Practice Address - Fax:435-719-5501
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1957034405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR34626Medicare UPIN