Provider Demographics
NPI:1235150921
Name:KOPISCH, MELODY (NP)
Entity Type:Individual
Prefix:MS
First Name:MELODY
Middle Name:
Last Name:KOPISCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CASA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1883
Mailing Address - Country:US
Mailing Address - Phone:805-544-8811
Mailing Address - Fax:805-548-0777
Practice Address - Street 1:100 CASA ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1883
Practice Address - Country:US
Practice Address - Phone:805-544-8811
Practice Address - Fax:805-544-8997
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2278363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology