Healthcare Provider Details

I. General information

NPI: 1275466062
Provider Name (Legal Business Name): AMANDA MELLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

1360 NE WESTVIEW DR
MADRAS OR
97741-9006
US

V. Phone/Fax

Practice location:
  • Phone: 866-626-2878
  • Fax:
Mailing address:
  • Phone: 805-390-1585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: