Healthcare Provider Details

I. General information

NPI: 1326030867
Provider Name (Legal Business Name): MELISSA CLARICE KOMROSKY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE SUITE 100
SAN JOSE CA
95128-2631
US

IV. Provider business mailing address

16770 CABERNET CIR
MORGAN HILL CA
95037-7081
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-5167
  • Fax: 408-885-5169
Mailing address:
  • Phone: 650-224-4854
  • Fax: 408-782-8780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 611446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: