1174021521 NPI number — MRS. CHARINA GELLACO QUIAMBAO FNP

Table of content: MRS. CHARINA GELLACO QUIAMBAO FNP (NPI 1174021521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174021521 NPI number — MRS. CHARINA GELLACO QUIAMBAO FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUIAMBAO
Provider First Name:
CHARINA
Provider Middle Name:
GELLACO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174021521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 CUSTOMER CARE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATWATER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95301-5167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-384-6488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 FLORIDA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95350-4437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-492-7150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  95008419 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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