Healthcare Provider Details

I. General information

NPI: 1396916029
Provider Name (Legal Business Name): MELODY OAKS CN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21731 N 86TH LN
PEORIA AZ
85382-2497
US

IV. Provider business mailing address

21731 N 86TH LN
PEORIA AZ
85382-2497
US

V. Phone/Fax

Practice location:
  • Phone: 602-469-3645
  • Fax: 623-321-1616
Mailing address:
  • Phone: 602-469-3645
  • Fax: 623-321-1616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number501001
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: