Healthcare Provider Details

I. General information

NPI: 1407318561
Provider Name (Legal Business Name): MELICIA IRENE NEAVILLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6524 W SACK DR STE 201
GLENDALE AZ
85308-7549
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0935
  • Fax: 602-933-2471
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7595
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: