Healthcare Provider Details

I. General information

NPI: 1770619298
Provider Name (Legal Business Name): DETRAH ELLEN HELE LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4670 N SECOND ST
FRESNO CA
93726
US

IV. Provider business mailing address

4670 N SECOND ST
FRESNO CA
93726
US

V. Phone/Fax

Practice location:
  • Phone: 559-221-7579
  • Fax:
Mailing address:
  • Phone: 559-221-7579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM 194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: