Healthcare Provider Details

I. General information

NPI: 1508020579
Provider Name (Legal Business Name): KATHLEEN ANN NYBERG RN, FNP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 E ALMOND AVE
MADERA CA
93637-5606
US

IV. Provider business mailing address

1222 E CROMWELL AVE
FRESNO CA
93720-2653
US

V. Phone/Fax

Practice location:
  • Phone: 559-675-5530
  • Fax:
Mailing address:
  • Phone: 559-439-7481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number215879
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: