Provider Demographics
NPI:1518503945
Name:MARTIN, MELANIE (DNP)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S TOOLE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-1814
Mailing Address - Country:US
Mailing Address - Phone:520-323-1312
Mailing Address - Fax:520-623-9964
Practice Address - Street 1:250 S TOOLE AVE STE B
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-1814
Practice Address - Country:US
Practice Address - Phone:520-323-1312
Practice Address - Fax:520-623-9964
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN126556363LF0000X
MARN2339231363LF0000X, 363LP0808X
AZAP234901363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ007900Medicaid