Healthcare Provider Details

I. General information

NPI: 1740004944
Provider Name (Legal Business Name): DEANDRA LEERINE BUCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 TULLY RD
MODESTO CA
95350-0811
US

IV. Provider business mailing address

3200 TULLY RD
MODESTO CA
95350-0811
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-2283
  • Fax: 209-576-2838
Mailing address:
  • Phone: 209-576-2283
  • Fax: 209-576-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: