Provider Demographics
NPI:1932983772
Name:BALTAZAR, MELISSA M (DNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2630
Mailing Address - Country:US
Mailing Address - Phone:619-770-3346
Mailing Address - Fax:
Practice Address - Street 1:5998 ALCALA PARK
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-8001
Practice Address - Country:US
Practice Address - Phone:619-260-4548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026239363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily