Healthcare Provider Details

I. General information

NPI: 1225738636
Provider Name (Legal Business Name): MELISSA AMBER GUMMO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13299 E COLOSSAL CAVE RD
VAIL AZ
85641-9001
US

IV. Provider business mailing address

13299 E COLOSSAL CAVE RD
VAIL AZ
85641-9001
US

V. Phone/Fax

Practice location:
  • Phone: 520-762-5200
  • Fax:
Mailing address:
  • Phone: 520-762-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023005857
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN176794
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: