Healthcare Provider Details

I. General information

NPI: 1124683008
Provider Name (Legal Business Name): JOANNA KRISTINE AFFOLTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOANNA KRISTINE CLEMENS RN

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

24240 AWAHANEE RD
SONORA CA
95370-8333
US

V. Phone/Fax

Practice location:
  • Phone: 209-300-8800
  • Fax:
Mailing address:
  • Phone: 209-694-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95053961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: