Basic Information
| Provider Information | |||||||||
| NPI: | 1275251373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2082 WENTE WAY | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951255998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193928672 | ||||||||
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| Practice Location | |||||||||
| Address1: | 747 EAST CHANNEL ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952022628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099444700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95022022 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.