Basic Information
| Provider Information | |||||||||
| NPI: | 1023255841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREA-RYAN | ||||||||
| FirstName: | MECHELLE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEREA | ||||||||
| OtherFirstName: | MECHELLE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093831848 | ||||||||
| FaxNumber: | 2093831296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 LAS VEGAS ST | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953585500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095764200 | ||||||||
| FaxNumber: | 2095565064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 12/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN445148 | CA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | NP9455 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP9455 | 01 | CA | MEDICAL LICENSE | OTHER |