Healthcare Provider Details

I. General information

NPI: 1689399446
Provider Name (Legal Business Name): MELINDA ANN RUSANOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 E SOUTHERN AVE
TEMPE AZ
85282-7649
US

IV. Provider business mailing address

16813 S 36TH ST
PHOENIX AZ
85048-7955
US

V. Phone/Fax

Practice location:
  • Phone: 480-756-6965
  • Fax: 480-384-5678
Mailing address:
  • Phone: 480-338-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number281802
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: