Provider Demographics
NPI:1285617449
Name:PRESTON, MELINDA A (NP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:A
Last Name:PRESTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:P
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1335 E ELLIS DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7261
Mailing Address - Country:US
Mailing Address - Phone:480-251-8689
Mailing Address - Fax:
Practice Address - Street 1:16601 N 40TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3345
Practice Address - Country:US
Practice Address - Phone:480-251-8689
Practice Address - Fax:602-795-2608
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP0004363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259A380OtherTRIWEST
AZZ128624OtherPTAN
AZ398306Medicaid
AZ500002997OtherRAILROAD MEDICARE
S43626Medicare UPIN
AZ20655Medicare ID - Type Unspecified