Provider Demographics
NPI:1528772019
Name:MELLINGER, MARIAH (NP)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:MELLINGER
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 1:13334 RED CLOUD LN
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-5155
Mailing Address - Country:US
Mailing Address - Phone:858-382-4955
Mailing Address - Fax:
Practice Address - Street 1:7944 BIRMINGHAM DR STE 76
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2705
Practice Address - Country:US
Practice Address - Phone:858-939-6764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18414363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner