Provider Demographics
NPI:1063233831
Name:KACZMAREK, MELINDA ASHLEY
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ASHLEY
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:ASHLEY
Other - Last Name:HADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1522 BLEECKER ST.
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-9063
Mailing Address - Country:US
Mailing Address - Phone:740-602-0506
Mailing Address - Fax:
Practice Address - Street 1:1975 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2351
Practice Address - Country:US
Practice Address - Phone:415-476-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026027363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care