Healthcare Provider Details

I. General information

NPI: 1063274025
Provider Name (Legal Business Name): MELISSA JEAN RUTHERFORD MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 W BASELINE RD
MESA AZ
85210-5971
US

IV. Provider business mailing address

2526 N USERY PASS RD
MESA AZ
85207-1578
US

V. Phone/Fax

Practice location:
  • Phone: 480-559-3149
  • Fax:
Mailing address:
  • Phone: 480-980-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number300743
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: