MEDICARE: MELISSA FILLMORE PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	RN.428291	OH
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	NP95013755	CA

General Provider Information

NPI Number	:	1356855142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA FILLMORE PMHNP-BC

Provider Business Mailing Address
First Line	:	2001 WILSHIRE BLVD STE 320
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5683
Country	:	US
Telephone Number	:	310-566-2006
Fax Number	:	424-322-1214

Provider Business Practice Location Address
First Line	:	2001 WILSHIRE BLVD STE 320
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5683
Country	:	US
Telephone Number	:	310-566-2006
Fax Number	:	424-322-1214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2017
Last Update Date	:	02/27/2025

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