Healthcare Provider Details

I. General information

NPI: 1477009702
Provider Name (Legal Business Name): MELISSA LYNN KOLNIK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. MELISSA LYNN YOUNGBERG

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 03/22/2025
Certification Date: 03/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N NAVAJO DR
PAGE AZ
86040-0959
US

IV. Provider business mailing address

9632 N 19TH ST
PHOENIX AZ
85020-2320
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-2424
  • Fax:
Mailing address:
  • Phone: 218-428-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1223
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: