Healthcare Provider Details

I. General information

NPI: 1841430832
Provider Name (Legal Business Name): COLLEEN MESEROLL PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 SEBASTOPOL RD
SANTA ROSA CA
95407-6829
US

IV. Provider business mailing address

751 LOMBARDI CT
SANTA ROSA CA
95407-6793
US

V. Phone/Fax

Practice location:
  • Phone: 707-547-2222
  • Fax: 707-547-2229
Mailing address:
  • Phone: 707-547-2222
  • Fax: 707-547-2229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number8644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: