Healthcare Provider Details

I. General information

NPI: 1205407095
Provider Name (Legal Business Name): ERICA MAE TIDIANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 GLENN DR STE 235
FOLSOM CA
95630-3193
US

IV. Provider business mailing address

950 GLENN DR STE 235
FOLSOM CA
95630-3193
US

V. Phone/Fax

Practice location:
  • Phone: 916-209-0533
  • Fax: 916-209-4056
Mailing address:
  • Phone: 916-209-0533
  • Fax: 916-209-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: