Healthcare Provider Details

I. General information

NPI: 1184299943
Provider Name (Legal Business Name): BERTHA MELENDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 W CHAPMAN AVE STE 205
ORANGE CA
92868-2863
US

IV. Provider business mailing address

4437 OWENS ST UNIT 105
CORONA CA
92883-7396
US

V. Phone/Fax

Practice location:
  • Phone: 714-639-1815
  • Fax:
Mailing address:
  • Phone: 714-262-3596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: