Provider Demographics
NPI:1861722621
Name:MARK, MELISSA A (CRNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:VALDELLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-204-1591
Mailing Address - Fax:510-204-5749
Practice Address - Street 1:2001 DWIGHT WAY FL 2
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2608
Practice Address - Country:US
Practice Address - Phone:510-204-5770
Practice Address - Fax:510-204-5749
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP21279363L00000X
PASP010669363LA2100X
CA21279363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner