Provider Demographics
NPI:1508974791
Name:JETHANANDANI, MELISSA ANNE (NP)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANNE
Last Name:JETHANANDANI
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 1:245 11TH ST.
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103
Mailing Address - Country:US
Mailing Address - Phone:415-355-0311
Mailing Address - Fax:864-512-1823
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002315363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0891Medicaid
SCNP0891Medicaid
SC7842Medicare PIN