Healthcare Provider Details

I. General information

NPI: 1093379752
Provider Name (Legal Business Name): NATASHA NEELUM DOUGLASS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 6TH ST
MODESTO CA
95354-2203
US

IV. Provider business mailing address

1910 CUSTOMER CARE WAY
ATWATER CA
95301-5167
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-2845
  • Fax: 209-576-8842
Mailing address:
  • Phone: 209-384-6493
  • Fax: 855-202-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number843499
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: