Provider Demographics
NPI:1780605048
Name:BLOMENKAMP, MELAINA ZANELE (PA-C)
Entity type:Individual
Prefix:
First Name:MELAINA
Middle Name:ZANELE
Last Name:BLOMENKAMP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELAINA
Other - Middle Name:ZANELE
Other - Last Name:LELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 BRITE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7088
Mailing Address - Country:US
Mailing Address - Phone:928-854-2542
Mailing Address - Fax:
Practice Address - Street 1:3269 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2731363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ49433Medicare UPIN