Provider Demographics
NPI:1053520692
Name:MELVIN, PHYLLIS (RN,NP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:MELVIN
Suffix:
Gender:F
Credentials:RN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 MADEIRA DR
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-4333
Mailing Address - Country:US
Mailing Address - Phone:650-359-8745
Mailing Address - Fax:
Practice Address - Street 1:1520 MADEIRA DR
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-4333
Practice Address - Country:US
Practice Address - Phone:650-359-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171502363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner