Provider Demographics
NPI:1891038113
Name:CANNON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5838
Mailing Address - Country:US
Mailing Address - Phone:510-535-4463
Mailing Address - Fax:510-535-4494
Practice Address - Street 1:2950 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2228
Practice Address - Country:US
Practice Address - Phone:510-535-4463
Practice Address - Fax:510-535-4494
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X
CA86009985133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689863516Medicaid
CAHAP11743FOtherSOFP
CAFHC11743FMedicaid
CAHAP11743FOtherSOFP
CAFHC11743FMedicaid