=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891038113
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA CANNON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2013
-----------------------------------------------------
Last Update Date | 04/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2950 INTERNATIONAL BLVD
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94601-2228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-535-4463
-----------------------------------------------------
Fax | 510-535-4494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 FAIRMOUNT AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-5838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-535-4463
-----------------------------------------------------
Fax | 510-535-4494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133NN1002X
-----------------------------------------------------
Taxonomy Name | Nutrition Education Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 86009985
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------