Healthcare Provider Details

I. General information

NPI: 1235957549
Provider Name (Legal Business Name): STEPHANIE MELROSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 WYNN RD
LAS VEGAS NV
89103-5406
US

IV. Provider business mailing address

6355 S BUFFALO DR FL 3
LAS VEGAS NV
89113-2133
US

V. Phone/Fax

Practice location:
  • Phone: 702-871-5005
  • Fax: 702-871-1349
Mailing address:
  • Phone: 702-216-3346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3139
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: