Healthcare Provider Details

I. General information

NPI: 1841099629
Provider Name (Legal Business Name): IMANI MALIEKA RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5007 KENNETH AVE
FAIR OAKS CA
95628-5329
US

IV. Provider business mailing address

8862 ADUR RD
ELK GROVE CA
95624-5206
US

V. Phone/Fax

Practice location:
  • Phone: 530-746-1512
  • Fax:
Mailing address:
  • Phone: 925-877-1054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: