Healthcare Provider Details

I. General information

NPI: 1750122412
Provider Name (Legal Business Name): GRACE C MELLOY INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4169 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-6742
US

IV. Provider business mailing address

4169 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-6742
US

V. Phone/Fax

Practice location:
  • Phone: 505-261-9770
  • Fax: 505-212-6747
Mailing address:
  • Phone: 505-261-9770
  • Fax: 505-212-6747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2025-1132
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: