1790111003 NPI number — JULIE ANNE MENA RN BSN MSN CNS

Table of content: JULIE ANNE MENA RN BSN MSN CNS (NPI 1790111003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790111003 NPI number — JULIE ANNE MENA RN BSN MSN CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENA
Provider First Name:
JULIE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN BSN MSN CNS
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:
1790111003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 GREENLEY RD
Provider Second Line Business Mailing Address:
C/O ANTICOAGULATION CLINIC
Provider Business Mailing Address City Name:
SONORA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95370-5200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-536-3720
Provider Business Mailing Address Fax Number:
209-588-1570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19747 GREENLEY RD
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
SONORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95370-5998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-536-3720
Provider Business Practice Location Address Fax Number:
209-588-1570
Provider Enumeration Date:
09/18/2013

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: 364SG0600X , with the licence number:  CNS 3763 , 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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