Provider Demographics
NPI:1396217998
Name:NICKESON, MELISSA (RDA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:NICKESON
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SHAW AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4209
Mailing Address - Country:US
Mailing Address - Phone:559-439-5300
Mailing Address - Fax:
Practice Address - Street 1:1900 SHAW AVE STE 101
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-4209
Practice Address - Country:US
Practice Address - Phone:559-439-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant