Healthcare Provider Details

I. General information

NPI: 1164477683
Provider Name (Legal Business Name): KELLIE JEAN AMADOR M.S.N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVENUE
MODESTO CA
95350
US

IV. Provider business mailing address

2100 POWELL ST SUITE 900
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN538124
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: