Healthcare Provider Details

I. General information

NPI: 1891038113
Provider Name (Legal Business Name): MELISSA CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 INTERNATIONAL BLVD
OAKLAND CA
94601-2228
US

IV. Provider business mailing address

201 FAIRMOUNT AVE
OAKLAND CA
94611-5838
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-4463
  • Fax: 510-535-4494
Mailing address:
  • Phone: 510-535-4463
  • Fax: 510-535-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86009985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: