1720600364 NPI number — MS. AMANDA YVETTE THEOLET CLINICAL NURSE LEADE

Table of content: MS. AMANDA YVETTE THEOLET CLINICAL NURSE LEADE (NPI 1720600364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720600364 NPI number — MS. AMANDA YVETTE THEOLET CLINICAL NURSE LEADE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEOLET
Provider First Name:
AMANDA
Provider Middle Name:
YVETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CLINICAL NURSE LEADE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLGUIN
Provider Other First Name:
AMANDA
Provider Other Middle Name:
YVETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720600364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81 LAKESHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94132-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-978-6719
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2615 E CLINTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93703-2223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-225-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2020

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: 163WE0003X , with the licence number:  95210279 , 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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