1164739405 NPI number — GAELEN ELIZABETH STEVENS-NELSON

Table of content: GAELEN ELIZABETH STEVENS-NELSON (NPI 1164739405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164739405 NPI number — GAELEN ELIZABETH STEVENS-NELSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS-NELSON
Provider First Name:
GAELEN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1164739405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1266 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94607-2205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-531-3111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 23RD ST
Provider Second Line Business Practice Location Address:
BUILDING 9, ROOM 130
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94110-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-206-5270
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2010

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 74642. , 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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