Provider Demographics
NPI:1245439330
Name:OGDEN, MELISSA (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:OGDEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2331 HUALAPAI MOUNTAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6207
Mailing Address - Country:US
Mailing Address - Phone:928-773-2280
Mailing Address - Fax:928-773-2281
Practice Address - Street 1:2331 HUALAPAI MOUNTAIN RD STE A
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6207
Practice Address - Country:US
Practice Address - Phone:928-773-2280
Practice Address - Fax:928-773-2281
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP2762207Q00000X
AZAP2762363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ462784Medicaid
AZTAP2762OtherSTATE OF ARIZONA LICENSE