Provider Demographics
NPI:1013696244
Name:FAYRAM, MELISSA MARIAN (FNP-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIAN
Last Name:FAYRAM
Suffix:
Gender:F
Credentials: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:PO BOX 992
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:CA
Mailing Address - Zip Code:93440-0992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 E OCEAN AVE STE 2
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2500
Practice Address - Country:US
Practice Address - Phone:805-743-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily