Healthcare Provider Details

I. General information

NPI: 1790048767
Provider Name (Legal Business Name): YONIS A MUDEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2012
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2288 FULTON ST STE 309
BERKELEY CA
94704-1490
US

IV. Provider business mailing address

2288 FULTON ST STE 309
BERKELEY CA
94704-1490
US

V. Phone/Fax

Practice location:
  • Phone: 650-577-2097
  • Fax: 650-577-2098
Mailing address:
  • Phone: 510-517-3156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number21343
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21343
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number21343
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number3467
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: