Healthcare Provider Details

I. General information

NPI: 1922576826
Provider Name (Legal Business Name): MELANIE LYNNE STEWART AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE LYNNE COSTALES A.G.N.P.

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3342
  • Fax: 505-272-6692
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2018017305
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: