Provider Demographics
NPI:1124643366
Name:GONZALES, MELISSA (NURSE)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 ROCKROSE CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8882
Mailing Address - Country:US
Mailing Address - Phone:916-846-8596
Mailing Address - Fax:
Practice Address - Street 1:5422 CAVITT STALLMAN RD
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-9491
Practice Address - Country:US
Practice Address - Phone:916-771-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN682920164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse