Provider Demographics
NPI:1366336091
Name:CARLSON, MELANIE (NP)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 UNION ST APT 2505
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3645
Mailing Address - Country:US
Mailing Address - Phone:630-605-7015
Mailing Address - Fax:
Practice Address - Street 1:1425 FRAZEE RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4347
Practice Address - Country:US
Practice Address - Phone:619-393-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95311730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily