Healthcare Provider Details

I. General information

NPI: 1114008422
Provider Name (Legal Business Name): JACQUELINE L PITTS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 MOWRY AVE SUITE 116
FREMONT CA
94538-1737
US

IV. Provider business mailing address

1834 STONE AVE SUITE 2B
SAN JOSE CA
95125-1306
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-3398
  • Fax: 510-792-3951
Mailing address:
  • Phone: 408-995-0102
  • Fax: 408-995-0190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN395303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: