Healthcare Provider Details

I. General information

NPI: 1760180798
Provider Name (Legal Business Name): SAUDIA FATIMA WHITAKER AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 10/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 5TH ST
GUSTINE CA
95322-1514
US

IV. Provider business mailing address

PO BOX 579174
MODESTO CA
95357-9174
US

V. Phone/Fax

Practice location:
  • Phone: 209-854-3728
  • Fax:
Mailing address:
  • Phone: 209-918-5482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95022977
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: