Provider Demographics
NPI:1053070102
Name:ELIST, MELISSA LILIAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LILIAN
Last Name:ELIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5027 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4427
Mailing Address - Country:US
Mailing Address - Phone:818-388-6841
Mailing Address - Fax:
Practice Address - Street 1:5027 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4427
Practice Address - Country:US
Practice Address - Phone:818-388-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant