=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174120943
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELODY FATEHI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 02/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2507 EASTBLUFF DR
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-200-1655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6228 ORANGE ST APT 9
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-637-9069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1178024
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------