Healthcare Provider Details

I. General information

NPI: 1164559431
Provider Name (Legal Business Name): MELISSA DIANE THUN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST SUITE 704
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3851 ROSECRANS ST SUITE 704
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-5607
  • Fax: 619-692-5677
Mailing address:
  • Phone: 619-692-5607
  • Fax: 619-692-5677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number495115
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number495115
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: