Provider Demographics
NPI:1508490566
Name:MELLES, SAMUEL HAILE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:HAILE
Last Name:MELLES
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9639 SILVER MOON
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-6110
Mailing Address - Country:US
Mailing Address - Phone:210-748-8177
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4301
Practice Address - Country:US
Practice Address - Phone:510-642-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95211487163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse