=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043996853
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELINDA DORITY RN, LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2023
-----------------------------------------------------
Last Update Date | 11/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8201 S 51ST DR
-----------------------------------------------------
City | LAVEEN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-274-1541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8201 S 51ST DR
-----------------------------------------------------
City | LAVEEN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-274-1541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT-007728
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WM1400X
-----------------------------------------------------
Taxonomy Name | Nurse Massage Therapist (NMT)
-----------------------------------------------------
License Number | 111285
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------