Provider Demographics
NPI:1417185059
Name:DERDER, MELLISSA (LVN)
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:
Last Name:DERDER
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 1:457 SCARLET OAK DR
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-3221
Mailing Address - Country:US
Mailing Address - Phone:530-846-4888
Mailing Address - Fax:
Practice Address - Street 1:592 RIO LINDO AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1817
Practice Address - Country:US
Practice Address - Phone:530-891-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34371167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician