Healthcare Provider Details

I. General information

NPI: 1407480932
Provider Name (Legal Business Name): MELANIE LEE BOLTZE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12409 W INDIAN SCHOOL RD
AVONDALE AZ
85392-9502
US

IV. Provider business mailing address

12409 W INDIAN SCHOOL RD STE B210
AVONDALE AZ
85392-9505
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-9920
  • Fax: 623-935-9925
Mailing address:
  • Phone: 623-935-9920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number165689
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: