Provider Demographics
NPI:1568632503
Name:MENDENHALL, MELODY ANN (NP)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:ANN
Last Name:MENDENHALL
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 1:4676 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6601
Mailing Address - Country:US
Mailing Address - Phone:310-827-7707
Mailing Address - Fax:310-574-4002
Practice Address - Street 1:4676 ADMIRALTY WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6601
Practice Address - Country:US
Practice Address - Phone:310-827-7707
Practice Address - Fax:310-574-4002
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622889363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner