Healthcare Provider Details

I. General information

NPI: 1629350236
Provider Name (Legal Business Name): SOPHEA PANN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCENIC DR
MODESTO CA
95350-6131
US

IV. Provider business mailing address

1904 RICHLAND AVE BLDG C-2
CERES CA
95307-4562
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4600
  • Fax:
Mailing address:
  • Phone: 209-525-5079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number792247
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number22774
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number792247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: