Healthcare Provider Details

I. General information

NPI: 1629471453
Provider Name (Legal Business Name): MELISSA RENE HUTZELL ATC, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PANTHER WAY
VISTA CA
92084-3128
US

IV. Provider business mailing address

2943 BOUNDARY ST
SAN DIEGO CA
92104-5206
US

V. Phone/Fax

Practice location:
  • Phone: 760-726-5611
  • Fax:
Mailing address:
  • Phone: 209-401-5717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: