Provider Demographics
NPI:1558764118
Name:COUNTZ, MELISSA (LVN)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:COUNTZ
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 1:2857 SHADOW CANYON CIR
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-1147
Mailing Address - Country:US
Mailing Address - Phone:909-573-7983
Mailing Address - Fax:
Practice Address - Street 1:2857 SHADOW CANYON CIR
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-1147
Practice Address - Country:US
Practice Address - Phone:909-573-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA226665164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse