Provider Demographics
NPI:1780354134
Name:MELLON, SUZANNE (NP, RN)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:LAVESQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1524 MCHENRY AVE, SUITE 405
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1524 MCHENRY AVE, SUITE 405
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-575-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA766317163W00000X
CA95014427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse