Healthcare Provider Details

I. General information

NPI: 1194327676
Provider Name (Legal Business Name): NICANORA ANDAZOLA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LLEWELLYN AVE # 408379
CAMPBELL CA
95008-1940
US

IV. Provider business mailing address

251 LLEWELLYN AVE # 408370
CAMPBELL CA
95008-1940
US

V. Phone/Fax

Practice location:
  • Phone: 408-379-3790
  • Fax:
Mailing address:
  • Phone: 408-379-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: