1790131373 NPI number — MELISSA DIANE MEEHAN MSN, RN, CNS

Table of content: MELISSA DIANE MEEHAN MSN, RN, CNS (NPI 1790131373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790131373 NPI number — MELISSA DIANE MEEHAN MSN, RN, CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEEHAN
Provider First Name:
MELISSA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, CNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DRAKE
Provider Other First Name:
MELISSA
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790131373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2681 W CANYON AVE
Provider Second Line Business Mailing Address:
APT 547
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-4736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-846-4098
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2681 W CANYON AVE
Provider Second Line Business Practice Location Address:
APT 547
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-4736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-846-4098
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WM0705X , with the licence number:  415908 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SM0705X , with the licence number: 4444 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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