Provider Demographics
NPI:1417526146
Name:MELANCON, BRIAN MARK (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARK
Last Name:MELANCON
Suffix:
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 PROJECT RD
Mailing Address - Street 2:
Mailing Address - City:IVA
Mailing Address - State:SC
Mailing Address - Zip Code:29655-9055
Mailing Address - Country:US
Mailing Address - Phone:864-616-1062
Mailing Address - Fax:
Practice Address - Street 1:6 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:DUE WEST
Practice Address - State:SC
Practice Address - Zip Code:29639-9554
Practice Address - Country:US
Practice Address - Phone:864-379-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25065363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily