Healthcare Provider Details

I. General information

NPI: 1356855142
Provider Name (Legal Business Name): MELISSA FILLMORE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 WILSHIRE BLVD STE 320
SANTA MONICA CA
90403-5683
US

IV. Provider business mailing address

2001 WILSHIRE BLVD STE 320
SANTA MONICA CA
90403-5683
US

V. Phone/Fax

Practice location:
  • Phone: 310-566-2006
  • Fax: 424-322-1214
Mailing address:
  • Phone: 310-566-2006
  • Fax: 424-322-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN.428291
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95013755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: