Healthcare Provider Details

I. General information

NPI: 1821552365
Provider Name (Legal Business Name): FANTA MBOKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE BLDG A
CERES CA
95307-4562
US

IV. Provider business mailing address

4211 MOTIF CT
TURLOCK CA
95382-7399
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number739503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: