Healthcare Provider Details

I. General information

NPI: 1093227258
Provider Name (Legal Business Name): MELISSA VAN FOSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

451 SALISBURY LN
CLAREMONT CA
91711-1936
US

V. Phone/Fax

Practice location:
  • Phone: 909-697-0571
  • Fax:
Mailing address:
  • Phone: 909-697-0571
  • Fax: 909-697-0571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: