Provider Demographics
NPI:1053961136
Name:MONDRAGON, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MONDRAGON
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 1:208 CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032
Mailing Address - Country:US
Mailing Address - Phone:408-806-8117
Mailing Address - Fax:
Practice Address - Street 1:208 CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-5401
Practice Address - Country:US
Practice Address - Phone:408-806-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12345OtherHEALTH
12345OtherHEALTH