Healthcare Provider Details

I. General information

NPI: 1164006839
Provider Name (Legal Business Name): BRIANNA MICHELLE MELLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 N LAQUINTA DR
ST GEORGE UT
84770-1928
US

IV. Provider business mailing address

4 N LAQUINTA DR
ST GEORGE UT
84770-1928
US

V. Phone/Fax

Practice location:
  • Phone: 774-991-2722
  • Fax:
Mailing address:
  • Phone: 774-991-2722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13061249-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: