Healthcare Provider Details

I. General information

NPI: 1114969896
Provider Name (Legal Business Name): MELANIE M UKANWA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 MONTGOMERY BLVD NE STE 220
ALBUQUERQUE NM
87109-1130
US

IV. Provider business mailing address

PO BOX 27453
ALBUQUERQUE NM
87125-7453
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-5307
  • Fax: 505-908-3816
Mailing address:
  • Phone: 505-881-5307
  • Fax: 505-908-3816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD20060291
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD20060291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: