Provider Demographics
NPI:1134797996
Name:SONG, MELINDA ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ELIZABETH
Last Name:SONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 MIRACERROS LOOP S
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4024
Mailing Address - Country:US
Mailing Address - Phone:505-620-5497
Mailing Address - Fax:
Practice Address - Street 1:1911 5TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5403
Practice Address - Country:US
Practice Address - Phone:505-780-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM62328363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care