Provider Demographics
NPI:1043520281
Name:SALASSA, MICHONNA MARIE (LVN)
Entity Type:Individual
Prefix:
First Name:MICHONNA
Middle Name:MARIE
Last Name:SALASSA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18116 LEMON ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-5417
Mailing Address - Country:US
Mailing Address - Phone:760-981-9506
Mailing Address - Fax:
Practice Address - Street 1:18116 LEMON ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-5417
Practice Address - Country:US
Practice Address - Phone:760-981-9506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 218469164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse