Healthcare Provider Details

I. General information

NPI: 1336121094
Provider Name (Legal Business Name): MELANIE DANE LOGUE PHD, DNP, APRN, CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VALE TERRACE DR
VISTA CA
92084
US

IV. Provider business mailing address

11575 W CANDELILLA WAY
PEORIA AZ
85383-4556
US

V. Phone/Fax

Practice location:
  • Phone: 308-500-3844
  • Fax:
Mailing address:
  • Phone: 235-232-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP0835
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95008920
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF95008920
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN083247
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95148897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: