Provider Demographics
NPI:1851870059
Name:PHOENIX, MELINDA L (LAC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:L
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-3452
Mailing Address - Country:US
Mailing Address - Phone:831-535-8582
Mailing Address - Fax:
Practice Address - Street 1:688 BROADWAY
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7000
Practice Address - Country:US
Practice Address - Phone:831-535-8582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17700171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist