Healthcare Provider Details

I. General information

NPI: 1639663248
Provider Name (Legal Business Name): AMANDEEP KAUR JOHAL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. AMANDEEP KAUR UPPAL

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 MAIN ST
LIVINGSTON CA
95334
US

IV. Provider business mailing address

1140 MAIN ST
LIVINGSTON CA
95334-1257
US

V. Phone/Fax

Practice location:
  • Phone: 209-394-7913
  • Fax:
Mailing address:
  • Phone: 209-394-7913
  • Fax: 209-394-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95009408
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95063589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: