Provider Demographics
NPI:1760126353
Name:MELACHOURIS, KERRY (RN PMHNP STUDENT)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:MELACHOURIS
Suffix:
Gender:F
Credentials:RN PMHNP STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30862 LA MER
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5511
Mailing Address - Country:US
Mailing Address - Phone:949-697-0960
Mailing Address - Fax:
Practice Address - Street 1:30862 LA MER
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5511
Practice Address - Country:US
Practice Address - Phone:949-697-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2024-08-01
Deactivation Date:2023-02-22
Deactivation Code:
Reactivation Date:2024-08-01
Provider Licenses
StateLicense IDTaxonomies
CA698539163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health