Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | AZ979 | AZ |
NPI | 1013064120 |
---|---|
Provider Name | Dr. Kirsten M Mellinger |
First Address | Flagstaff, AZ 86001-4852 |
Second Address | Flagstaff, AZ 86001-4852 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 12/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U68143 | (02) | AZ |