Provider Demographics
NPI:1952008419
Name:PETERSON, MELINDA LEE (APRN)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:ESCALANTE
Mailing Address - State:UT
Mailing Address - Zip Code:84726-0036
Mailing Address - Country:US
Mailing Address - Phone:435-690-9510
Mailing Address - Fax:
Practice Address - Street 1:200 N 400 E
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759-7803
Practice Address - Country:US
Practice Address - Phone:435-676-8842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8054803-4405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine