Healthcare Provider Details

I. General information

NPI: 1962048488
Provider Name (Legal Business Name): MELLANY ANN AQUINO PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELLANY GLINO

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUMMIT ST
OAKLAND CA
94609-3412
US

IV. Provider business mailing address

290 PACIFICA DR
BRENTWOOD CA
94513-1394
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3885
  • Fax:
Mailing address:
  • Phone: 650-455-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95013266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: