Provider Demographics
NPI:1114359270
Name:NORTHAM, MELISSA GAYLE (LVN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GAYLE
Last Name:NORTHAM
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 1:1675 MORENA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3703
Mailing Address - Country:US
Mailing Address - Phone:619-275-8000
Mailing Address - Fax:
Practice Address - Street 1:1675 MORENA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3703
Practice Address - Country:US
Practice Address - Phone:619-275-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240523164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse