Provider Demographics
NPI:1518519610
Name:MELANCON, CARLY MICHELLE (MSN, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MICHELLE
Last Name:MELANCON
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W KOENIG LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-1208
Mailing Address - Country:US
Mailing Address - Phone:512-808-0543
Mailing Address - Fax:
Practice Address - Street 1:1801 W KOENIG LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-1208
Practice Address - Country:US
Practice Address - Phone:512-808-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142178363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health