Healthcare Provider Details

I. General information

NPI: 1659550747
Provider Name (Legal Business Name): MELINDA JILL PORTER RN, NNP-BC, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MERCED STREET 3RD FLOOR, NICU
SAN LEANDRO CA
94577-4201
US

IV. Provider business mailing address

2500 MERCED STREET 3RD FLOOR, NICU
SAN LEANDRO CA
94577-4201
US

V. Phone/Fax

Practice location:
  • Phone: 510-454-3546
  • Fax:
Mailing address:
  • Phone: 510-454-3546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN536076
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number13535
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code364SN0000X
TaxonomyNeonatal Clinical Nurse Specialist
License Number1689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: