Healthcare Provider Details

I. General information

NPI: 1811552540
Provider Name (Legal Business Name): MELANIE J BULIYAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

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

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

2433 HANCOCK DR
FAIRFIELD CA
94533-1561
US

V. Phone/Fax

Practice location:
  • Phone: 707-816-5610
  • Fax:
Mailing address:
  • Phone: 707-816-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number691007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: