Basic Information
| Provider Information | |||||||||
| NPI: | 1730493859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA MORA | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956080306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165375000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6501 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165375000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2010 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 20747 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1730493859 | 05 | CA | MEDICAID |