Healthcare Provider Details

I. General information

NPI: 1205643749
Provider Name (Legal Business Name): MELANIE FERNANDEZ BACCAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

9014 CAMBRIDGE CIR
VALLEJO CA
94591-8593
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-4426
  • Fax:
Mailing address:
  • Phone: 510-417-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95041098
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number754607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: