Provider Demographics
NPI:1356855142
Name:FILLMORE, MELISSA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FILLMORE
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 WILSHIRE BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5683
Mailing Address - Country:US
Mailing Address - Phone:310-566-2006
Mailing Address - Fax:424-322-1214
Practice Address - Street 1:2001 WILSHIRE BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5683
Practice Address - Country:US
Practice Address - Phone:310-566-2006
Practice Address - Fax:424-322-1214
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.428291163WP0807X
CANP95013755363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent