Healthcare Provider Details

I. General information

NPI: 1154986743
Provider Name (Legal Business Name): MELANIE SULJADA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5924 E LOS ANGELES AVE STE R
SIMI VALLEY CA
93063-5526
US

IV. Provider business mailing address

5924 E LOS ANGELES AVE STE R
SIMI VALLEY CA
93063-5526
US

V. Phone/Fax

Practice location:
  • Phone: 818-317-9520
  • Fax:
Mailing address:
  • Phone: 818-317-9520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95011057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: