Provider Demographics
NPI:1003918947
Name:MEDELLIN, MELISSA A (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MEDELLIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:VALDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1002 N FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-1811
Mailing Address - Country:US
Mailing Address - Phone:714-835-8501
Mailing Address - Fax:
Practice Address - Street 1:1002 N FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-1811
Practice Address - Country:US
Practice Address - Phone:714-835-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00NP151890Medicaid