Provider Demographics
NPI:1083028930
Name:PETERSON, MELISSA ANNE (RN, MSN, CPNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN, MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 SUNSET BLVD.
Mailing Address - Street 2:MAIL STOP #66
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027
Mailing Address - Country:US
Mailing Address - Phone:323-361-4148
Mailing Address - Fax:323-361-3668
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-4148
Practice Address - Fax:323-361-3668
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033179163WP0200X
CA95000725363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics