Healthcare Provider Details

I. General information

NPI: 1710984828
Provider Name (Legal Business Name): CLAUDIA POGUE BLICK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 N COTTAGE AVE
MANTECA CA
95336-4942
US

IV. Provider business mailing address

296 N COTTAGE AVE
MANTECA CA
95336-4942
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-2901
  • Fax: 209-239-8662
Mailing address:
  • Phone: 209-239-2901
  • Fax: 209-239-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number602107
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: