Provider Demographics
NPI:1922576826
Name:STEWART, MELANIE LYNNE (AGNP)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:LYNNE
Last Name:STEWART
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:LYNNE
Other - Last Name:COSTALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGNP
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-3342
Practice Address - Fax:505-272-6692
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2018017305363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2018017305Medicaid