MEDICARE: MELISSA A. MCKINNEY, D.O., P.L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	4057	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z104516	OTHER	AZ	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1932379658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELISSA A. MCKINNEY, D.O., P.L.L.C.

Provider Business Mailing Address
First Line	:	2370 W HWY 89A #11 PMB 412
Second Line	:
City	:	SEDONA
State	:	AZ
Zip	:	86336-5341
Country	:	US
Telephone Number	:	928-592-9140
Fax Number	:	928-592-9144

Provider Business Practice Location Address
First Line	:	4283 PIMA WAY
Second Line	:
City	:	LAKE MONTEZUMA
State	:	AZ
Zip	:	86342-5087
Country	:	US
Telephone Number	:	928-592-9140
Fax Number	:	928-592-9144

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	MELISSA A. MCKINNEY
Credential	:	D.O.
Telephone Number	:	928-592-9140

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	03/14/2008

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