Provider Demographics
NPI:1972740306
Name:SMITH, MELANIE T (LMT #6275)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:T
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT #6275
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SUNSET RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4008
Mailing Address - Country:US
Mailing Address - Phone:505-414-4810
Mailing Address - Fax:
Practice Address - Street 1:1300 SUNSET RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4008
Practice Address - Country:US
Practice Address - Phone:505-414-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist