Healthcare Provider Details

I. General information

NPI: 1093170649
Provider Name (Legal Business Name): MARY CANDELARIA LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E KINGS CANYON
FRESNO CA
93702
US

IV. Provider business mailing address

4411 E KINGS CANYON RD
FRESNO CA
93702
US

V. Phone/Fax

Practice location:
  • Phone: 559-453-1008
  • Fax:
Mailing address:
  • Phone: 559-453-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number288041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: