Provider Demographics
NPI:1184494593
Name:SMITH, MELENA
Entity type:Individual
Prefix:
First Name:MELENA
Middle Name:
Last Name:SMITH
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 1:121 GLORIA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3620
Mailing Address - Country:US
Mailing Address - Phone:914-645-2153
Mailing Address - Fax:
Practice Address - Street 1:1283 GILMAN ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94706-2351
Practice Address - Country:US
Practice Address - Phone:510-214-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19916171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist