Healthcare Provider Details

I. General information

NPI: 1760914063
Provider Name (Legal Business Name): NADEREH FANAEIAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E KINGS CANYON RD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

4411 E KINGS CANYON RD
FRESNO CA
93702-3604
US

V. Phone/Fax

Practice location:
  • Phone: 559-538-1735
  • Fax: 559-453-2805
Mailing address:
  • Phone: 559-538-1735
  • Fax: 559-453-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number530465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: