Provider Demographics
NPI:1992356547
Name:MELILLO, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MELILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17525 VENTURA BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5111
Mailing Address - Country:US
Mailing Address - Phone:818-986-2861
Mailing Address - Fax:
Practice Address - Street 1:27700 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6426
Practice Address - Country:US
Practice Address - Phone:949-364-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant