Basic Information
| Provider Information | |||||||||
| NPI: | 1417185059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERDER | ||||||||
| FirstName: | MELLISSA | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 457 SCARLET OAK DR | ||||||||
| Address2: | |||||||||
| City: | GRIDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959483221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308464888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 592 RIO LINDO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959261817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308912999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 06/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT34371 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.